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RK531  L49  The  principles  and  p 


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Reference  Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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The 

Principles  and   Practice 
of  Tooth  Extraction 

and 
Local  Anesthesia  of  the  Maxillae 

By 

WILLIAM  J.  LEDERER,  D.D.S. 

Dental  Consultant  to  the  German  Hospital  in  the 
City  of  New  York 

Illustrated  with  120  Textual  Figures  and  H 
Figures  on  4  Plates 


NEW  YORK 

THE  REBMAN  COMPANY 

141-145  WEST  36th.  STREET 


Copyright,  1915 
By  REBMAN  COMPANY 

All  Rights  Reserved 


Printed  in  America, 


This  little   volume 
is  dedicated  to 
my  Father 

/ifor.  Emanuel  Xefcerer 


AUTHOR'S  NOTE 

In  offering  this  little  volume  the  author  does  not 
presume  to  have  fully  exhausted  his  subjects;  he 
presents  these  in  compend  form,  to  aid  both  the 
Dental  Student  and  Practitioner  and  recall  to 
their  minds  that  Tooth  Extraction  is  a  Surgical 
Procedure  and  must  be  carried  out  accordingly. 

The  chapters  on  Conductive  Anesthesia 
should  emphasize  the  great  value  of  this  method 
in  performing  painless  operations  about  the  teeth 
and  jaws.  Painless  Dentistry  is  not  a  dream  any 
more;  to-day  it  has  become  a  reality,  thanks  to 
Braun  and  Fischer. 

For  careful  study  the  succeeding  steps  of  the 
Mandibular  Injection  have  been  assembled  sepa- 
rately on  four  Plates,  Figures  106-112. 

The  author  expresses  his  sincere  thanks  to  the 
Dentists  Supply  Company,  The  S.  S.  White  Den- 
tal Mfg.  Co.,  as  well  as  to  the  Kny-Scherer  Co. 
for  the  loan  of  electrotypes,  and  also  to  the  Reb- 
man  Co.  for  the  interest  shown  and  valuable  as- 
sistance given  in  the  publication  of  this  book. 

William  J.  Lederer. 

150  East  Seventy-fourth  Street,  New  York. 


CONTENTS 

PART  I 

PAGE 

I.  Dental  and  Oral  Operations  in  Their 

True  Aspect 3 

II.  Sterilization: 

Cleanliness  and  Asepsis  ....  7 

Care  of  the  Operator's  Hands  .      .  9 

Care  of  Instruments 10 

III.  The  Relation  of  the  Operator  Toward 

His  Patient 12 

IV.  The  Examination  of  the  Patient   .      .  14 
V.  The  Preparation  of  the  Patient  .      .  22 

VI.  Indications  for  Tooth  Extraction     .  24 
VII.  The  Operator's  Armamentarium: 

Instruments,  Drugs  and  Dressings  .  26 

VIII.  Classification  of  Cases 40 

IX.  The   Technique   of    Normal   Extrac- 
tions      42 

X.  Root  Extractions 68 

XI.  Impacted  Teeth 80 

XII.  Unerupted  Teeth 91 

XIII.  Post  Extractive  Treatment      .      .      .  101 

XIV.  The  Treatment  ok  Complications     .  115 

v 


vi  Contents 

PART  II 

PAGE 

I.  Anesthesia: 

Geneeal,    Local,    Conductive,    Re- 
gional   129 

II.  Solutions  foe  Local  Anaesthesia  :  the 

Solvent  Medium 132 

III.  The  Aemamentaeium 138 

IV.  Cocaine,  Novocain,  Adeenalin  .      .      .   146 
V.  The   Technique   of   Local   (Infiltea- 

tion)   Anaesthesia 162 

VI.  Anatomical  Consideeations      .      .      .   172 
VII.  The  Technique  of  Conductive  Anaes- 
thesia   180 

VIII.  Indications     and      Conteaindications 
foe   Local  and   Conductive    (Re- 
gional)  Anaesthesia      ....   199 
IX.  Inhalation    Anaesthesia    veesus    Re- 
gional Anaesthesia 203 

X.  Shock  in  Oeal  Suegeey 207 

XI.  Recoeds  of  Conductive  Anaesthesias 
in  Oeal  Suegeey — Recoeds  of 
Conductive   Anaesthesias  in   Op- 

eeative  dentistey 209 

XII.  Useful  Foemulae  and  Peesceiptions   .   235 

XIII.  Poisons  and  Theie  Antidotes  .      .      .   243 

XIV.  The  Teeatment  of  Emeegencies  .      .   246 
XV.  Glossary 249 

XVI.  Index 259 


PART  ONE 

THE  PRINCIPLES  AND  PRACTICE  OF  TOOTH  EXTRACTION 


Dental  and  Oral  Operations  in  Their  True 
Aspect 

The  principles  of  surgery  are  always  the  same,  no 
matter  to  what  part  of  the  body  they  are  applied. 
Different  localities  of  the  body  vary  in  degree  of 
susceptibility  to  infection.  Thus  the  opening  of 
the  abdominal  cavity  or  the  exploration  of  the 
knee  joint  is  attended  by  more  apprehension  than 
the  incision  of  a  superficial  abscess  or  the  extrac- 
tion of  a  tooth ;  nevertheless,  the  latter  procedures 
are  surgical  operations  just  as  the  former,  and 
the  same  rules  must  be  observed. 

The  late  W.  D.  Miller,  in  his  work  on  "The  Mi- 
croorganisms of  the  Human  Mouth,"  collected  a 
list  of  165  cases  of  severe  infections  following  den- 
tal and  buccal  lesions,  of  which  more  than  60 
terminated  fatally.  Some  succumbed  to  heart  le- 
sions, others  developed  pulmonary  infections, 
others  meningitis,  cerebral  abscesses,  pyemia, 
septicemia,  Ludwig's  angina,  frontal  sinusitis, 
thrombosis,  etc.  Those  who  did  not  die,  carried 
off  syphilitic  infections,  and  those  who  finally  got 
well  went  through  long  suffering  and  a  trying 
convalescence.    These  cases  were  reported  by  men 

3 


4  Tooth  Extkaction 

like  Kirk,  Jack,  Wilson,  Darby,  Truman,  Marshall 
and  others  of  like  quality. 

Von  Mosetig-Moorhof,  the  eminent  Viennese 
surgeon,  reports  two  cases  in  which  extraction  of 
the  second  right  and  left  lower  molars,  re- 
spectively, was  attempted;  the  first  case  devel- 
oped gangrene  of  the  soft  tissues,  phlebitis, 
myelitis,  oedema  of  the  lungs,  and  died.  The  sec- 
ond patient  contracted  an  osteitis  followed  by 
phlebitis  and  pyemia,  and  also  terminated  fatally. 
In  both  instances  the  broken-ofr"  roots  had  been 
extracted,  drainage  established  by  deep  incisions, 
but  it  was  too  late. 

Schwendt  reports  a  case  wherein  the  extraction 
of  teeth  was  followed  by  infection  of  the  orbits, 
resulting  in  blindness.  Baume  speaks  of  a 
case  of  an  attempted  extraction  of  a  six-year 
molar  followed  by  periostitis,  necrosis,  pyemia, 
pleuro-broncho-pneumonia,  and  death  after  two 
weeks. 

Many  a  death  certificate  reads  myocarditis, 
nephritis,  or  pneumonia,  the  patient  is  laid  at  rest, 
and  the  fact  that  his  death  is  the  result  of  a  tooth 
lesion  is  not  known  either  to  his  physician  or  his 
dentist.  The  certificate  really  should  read  "Sep- 
tic endocarditis  produced  by  streptococci  which 
hailed  from  an  alveolar  abscess." 

How  can  such  severe  conditions  result  from  a 
localized    abscess?      Pathology    teaches    us    that 


Infections  followinc4  Dental  Operations     5 

when  pyogenic  organisms  reach  the  walls  of  blood 
vessels  they  may  set  up  a  phlebitis  (inflammation 
of  a  vein).  The  endothelial  lining  of  the  vessel 
is  broken  up,  leucocytes  collect  at  these  points,  and 
a  mass  is  formed  known  as  a  "white  thrombus." 
This  thrombus  becomes  infected  with  bacteria,  and 
is  broken  up,  loosens,  and  thus  becomes  an  em- 
bolism or  a  number  of  emboli.  These  masses  are 
carried  along  in  the  blood  stream  and  may  pro- 
duce metastatic  abscesses  or  infect  other  struc- 
tures ;  thus  reaching  the  right  heart,  an  endocar- 
ditis or  a  myocarditis  may  result;  or  the  septic 
masses  enter  the  pulmonary  system  and  produce 
lung  lesions,  or  they  enter  the  general  circula- 
tion by  the  left  heart  and  infect  other  remote 
structures. 

The  researches  of  Billings  and  Rosenow,  of 
Chicago,  and  Hartzell,  of  Minneapolis,  have 
proven  beyond  a  shadow  of  a  doubt  that  pyogenic 
foci  in  and  about  the  mouth  may  produce  distal 
lesions.  Henry  Hemsted,  in  the  London  Lancet  of 
January  4,  1913,  describes  a  case  of  streptococcus 
endocarditis  which  he  positively  traces  to  an  ab- 
Bcessed  tooth. 

Such  tilings  being  possible,  dental  and  oral 
operations  should  be  viewed  in  their  true  light, 
namely,  as  surgical  operations,  and  be  carried  out 
accordingly;  and  the  dental  and  buccal  specialist, 
whether  he  calls  himself  dental  surgeon,  stoma- 


6  Tooth  Extraction 

tologist,  oral  surgeon,  or  dentist,  must  accept  and 
apply  the  principles  of  general  surgery. 

Surgery  is  defined  as  that  branch  of  medicine 
dealing  with  disease  requiring  operative  pro- 
cedures ;  therefore,  any  operative  procedure  in  the 
mouth  is  mouth  surgery.  In  fact,  all  operations 
in  the  mouth  are  surgical  procedures,  excepting 
the  insertion  of  artificial  teeth  and  the  introduc- 
tion of  appliances  requisite  for  the  correction  of 
deformities  of  the  teeth  and  jaws.  The  insertion 
of  a  filling  is  plastic  dental  surgery  and  calls  for 
antiseptic  precaution,  a  principle  of  surgery;  the 
extraction  of  teeth  is  certainly  a  surgical  opera- 
tion and  requires  the  observation  of  surgical 
principles. 


II 

Sterilization 

1 .  Glea  nl  in  ess — A  sepsis 
The  first  principle  of  successful  surgery  is  the 
creation  and  maintenance  of  asepsis  as  far  as  pos- 
sible. A  good  deal  has  been  written  about  sterili- 
zation and  asepsis.  However,  the  author  finds 
that  many  men  have  not  learned  their  lesson  well, 
for  he  frequently  notes  a  lack  of  understanding 
of  the  basal  principles  of  asepsis  among  dentists. 
He  has  seen  good  operators  sterilize  a  pair  of  for- 
ceps prior  to  extraction,  and  then  pausing  to  re- 
examine the  tooth  to  be  removed,  deliberately 
place  the  sterile  instrument  into  their  operating 
coat  pocket,  whence  they  had  drawn  a  pencil  or 
pad  a  few  moments  previously. 

Some  dry  a  sterile  instrument  on  a  previously 
used  towel.  In  spite  of  knowing  the  meaning  of 
asepsis  and  sepsis,  they  lack  what  Dr.  Marshall 
calls  "the  sense  of  asepsis."  An  operator  must 
not  only  know  the  meaning  of  the  word  asepsis, 
he  must  feel  it ;  it  must  become  part  of  his  physical 
make-up.  Surgical  cleanliness  spells  absolute 
asepsis  (as  far  as  it  is  possible),  as  the  result  of 
any  operation  depends  in  a  large  measure  upon  the 
degree  of  asepsis  under  which  it  is  executed. 

7 


8  Tooth  Extr action 

Asepsis  for  the  mouth  specialist  means  aseptic 
hands,  aseptic  instruments,  aseptic  instrument  ta- 
ble, aseptic  field  of  operation.  There  are  dentists 
who  will  sterilize  their  instruments,  but  fail  to 
properly  cleanse  their  hands,  and  there  are  men 
who  carefully  observe  personal  cleanliness,  boil 
their  instruments,  but  fail  to  sterilize  their  im- 
pression cups.  Many  keep  sterile  instruments  in 
filthy  dental  cabinets;  by  filthy  cabinets  I  mean 
highly  polished  pieces  of  furniture  with  felt-lined 
drawers,  full  of  dust,  gold  scrap,  drugs,  sand  from 
polishing  discs,  in  short,  filthy  drawers  and  com- 
partments, which  become  the  receptacles  for 
sterile  instruments.  These  instruments  unavoid- 
ably become  tainted. 

In  how  many  offices  are  instruments  boiled  be- 
fore using?  Dipping  into  carbolic  acid  before 
using  is  not  practical;  in  fact,  all  dipping  is  bad 
sterilization,  unless  tr.  iodine  is  used,  and  this  is 
hard  upon  instruments.  All  partial  methods  of 
sterilization  are  bad ;  they  are  a  little  better  than 
no  attempt,  but  they  are  unscientific  and  directly 
criminal  toward  the  patient. 

The  new  departure  of  instrument  houses  to  con- 
struct dental  furniture  on  the  lines  of  surgical  fur- 
niture is  an  innovation  in  the  right  direction.  Den- 
tal and  buccal  operations  must  be  viewed  as  surgi- 
cal procedures  and  carried  out  accordingly.  The 
white-enamel  office  is  unquestionably  the  dental  of- 


Asepsis  9 

fice  of  the  future;  it  must  be  kept  clean,  and  the 
cleaner  an  operating  room  the  more  aseptic.  The 
following  is  the  plan  of  sterilization  pursued  by 
the  writer. 


2.  Care  of  the  Operator's  Hands 

In  surgical  cases  the  hands  and  arms  are 
brushed  thoroughly  with  hot  water  and  tr.  of 
green  soap.  Particular  attention  is  given  to  the 
nails,  which  are  pared  and  cleansed  with  nail  file 
and  orange-wood  stick.  The  hands  are  then  rinsed 
in  sterile  water,  bathed  in  alcohol,  and  immersed 
for  some  time  in  a  sublimate  solution.  If  rubber 
gloves  are  worn,  the  hands  are  dried  in  a  sterile 
towel  and  powdered  with  sterile  talcum  powder 
and  then  sterile  gloves  put  on.  If  there  are  any 
cuts  or  abrasions  upon  the  fingers,  these  are 
painted  with  a  coat  of  collodion.  In  daily  dental 
practice  (ordinary  cases)  the  thorough  brushing 
of  the  hands  and  fingers  with  a  good  soap  and  hot 
water  is  sufficient.  If  an  operator  is  treating  a 
syphilitic  patient  and  should  injure  the  skin,  the 
immediate  and  very  thorough  massage  of  the 
wound  with  33  1/3  per  cent,  calomel  ointment  is 
a  prophylactic  measure  against  infection.  The 
hands  must  always  be  very  thoroughly  dried  be- 
fore going  out  to  prevent  chapping. 


10  Tooth  Extraction 

3.  Care  of  Instruments 

All  instruments  are  boiled  in  water  to  which  a 
little  washing  soda  has  been  added.  After  use 
they  are  brushed  to  remove  blood,  pus,  and  tissue 
residue,  and  then  boiled,  dried  in  a  sterile  towel 
and  placed  in  a  cabinet.  Knives  after  brushing 
are  placed  in  lysol,  washed  in  alcohol,  and  put 
away.  Before  using  a  knife,  it  is  Traced  in  lysol, 
washed  in  alcohol,  but  not  dried.  The  author 
keeps  a  test  tube  half  filled  with  lysol,  wherein  a 
knife  is  placed  permanently,  ahvays  ready  for  use. 

Hypodermic  syringes  are  washed  out  with  sterile 
water  and  then  kept  in  70  per  cent,  alcohol.  Hy- 
podermic needles  are  cleansed  by  attaching  to  the 
syringe,  passing  wTater  through,  then  detaching 
them,  drawing  a  wire  through  the  cannula,  and 
boiling.  After  boiling  they  are  placed  in  pure 
lysol  and  kept  there  until  used.  Before  using,  all 
traces  of  lysol  must  be  removed  by  washing  first 
in  alcohol  and  then  in  sterile  water. 

Mirrors  are  brushed  and  boiled.  It  is  better  to 
increase  the  mirror  bill  than  to  run  chances  of  im- 
perfect sterilization.  All  instruments  are  handled 
with  forceps  and  placed  upon  a  sterile  glass  tray. 
After  use  they  are  placed  upon  a  metal  tray,  which 
is  thrown  into  the  sterilizer  with  the  instruments. 
The  assistant  never  touches  the  unused  instrument 
with  her  hands,  always  using  forceps.  This 
method  of  sterilization  is  simple,  practical  and  ef- 


Sterilization'  11 

fective.  It  takes  but  a  short  time  to  become  ac- 
customed to  it,  and  once  acquired  demands  little 
effort. 

Nerve  broaches  are  passed  through  a  piece  of 
tightly  stretched  rubber  dam  to  remove  adhering 
tissue,  then  boiled  and  rinsed  in  alcohol  for  dry- 
ing. To  save  time,  each  instrument  which  is  fre- 
quently used  should  exist  in  duplicate  or  triplet 
form,  such  as  scalers,  chisels  and  excavators. 
This  means  a  little  increased  initial  expense,  but 
additional  safety  forever. 

Drinking  glasses  should  never  be  employed,  but 
the  always  sterile  paper  cup  be  in  use.  Napkins 
and  towels  are  changed  for  each  patient  and  ster- 
ilized by  washing,  provided  they  are  boiled  in  the 
laundry.  The  author  had  his  chair  covered  with 
rubber  cloth  slip  covers;  the  chair  arms  are  of 
enamel ;  both  are  washed  after  a  patient  leaves  the 
chair.  The  top  of  the  swinging  table  should  be 
interchangeable,  so  that  it  can  be  sterilized  by 
washing  and  wiping  it  with  alcohol  after  each 
treatment  or  operation.  This  apparent  over- 
use of  alcohol  may  seem  expensive,  but  the  writer 
does  not  use  over  $10  worth  of  this  drug  through- 
out the  year,  which  is  hardly  worth  mentioning  in 
return  for  the  safety  felt  by  both  operator  and 
patient. 


Ill 

The  Relation  of  the  Operator  Toward  His 

Patient 

Tooth  extraction  appears  to  be  a  simple  pro- 
cedure, demanding  little  skill.  If  the  operator 
proceeds  in  this  spirit  he  will  soon  learn  that  suc- 
cessful extracting  is  not  merely  "tooth  pulling," 
but  that  considerable  skill  and  judgment  are  re- 
quired. It  is  impossible  for  any  intelligent  prac- 
titioner to  adhere  to  any  fixed  set  of  rules,  as 
every  new  case  differs  from  its  predecessor  and 
patients  vary  in  physical  and  mental  make-up  and 
teeth  and  jaws  differ  anatomically. 

Before  discussing  the  actual  modus  operandi, 
the  writer  desires  to  speak  of  a  very  important 
factor,  namely,  the  attitude  of  the  operator  to- 
ward his  patient.  The  first  essential  for  the  opera- 
tor is  absolute  calmness,  for  self-control  and  pre- 
cision of  action  will  inspire  confidence.  Never 
hurry;  you  cannot  extract  teeth  successfully  by 
the  clock.  The  patient  must  always  feel  that  the 
operator  is  the  master  of  the  situation.  Some- 
times the  operator  is  confronted  by  a  difficult 
problem  and  may  be  at  a  loss  which  course  to 
pursue;  let  him  carefully  weigh  the  several  pos- 
sibilities and  then  proceed.     The  operator  must 

12 


Attitude  of  Operator  13 

never  exhibit  stage  fright  or  appear  overwhelmed 
by  the  situation.  A  kind,  gentle  word,  especially 
to  women  and  children,  will  do  more  to  quiet  the 
patient  than  the  pompous,  ultra-professional  air 
assumed  by  some.  Kind  but  firm,  never  rough  or 
impatient,  should  be  the  attitude  of  the  operator. 
Men's  successes  can  more  often  be  traced  to  their 
attitude  toward  their  patients  than  to  exceptional 
skill  or  ability.  In  treating  children  or  extremely 
nervous  patients,  some  men  have  recourse  to  a 
falsehood,  assuring  them  that  this  or  that  will  not 
hurt,  thus  gaining  their  confidence,  and  they  per- 
form some  painful  operation,  as  the  extraction  of 
a  tooth  or  the  removal  of  a  pulp.  This  the  writer 
absolutely  condemns.  Never  tell  a  patient  a  lie. 
Do  the  least  painful  work  first,  gain  the  patient's 
confidence,  and  then  he  will  submit  even  to  neces- 
sarily painful  operations. 


IV 

The  Examination  of  the  Patient 

The  examination  of  the  patient  should  begin 
the  moment  he  enters  the  office,  as  many  objective 
symptoms,  valuable  to  the  operator,  can  be  elicited 
by  careful  observation, 

Common  sense  will  forbid  a  long,  painful  ses- 
sion with  a  nervously  agitated  subject,  the  danger 
from  shock  being  greater  here  than  in  the  case 
of  a  robust  individual.  A  strong  person  will  with- 
stand the  extraction  of  a  number  of  teeth  without 
an  anaesthetic,  while  a  delicate  patient  may  not 
bear  a  superficial  scaling.  A  stout  asthmatic  is 
as  unfit  for  a  long  session  as  a  neurasthenic,  whose 
confidence  can  only  be  gained  by  short  sittings  and 
the  least  painful  methods.  A  heart  lesion  can  fre- 
quently be  noted  by  the  congested  appearance  of 
the  mucous  membrane,  club  shaped  fingers,  ve- 
nosity  of  the  nails,  indicating  an  obstructed  cir- 
culation. Extreme  pallor  may  indicate  anaemia  or 
a  weak,  inefficient  heart.  Prominent  temporal  ar- 
teries, standing  out  like  whipcords,  indicate  a 
hardened  condition  of  the  blood  vessels  and  the 
radial  pulse  should  be  tested,  as  to  the  compressi- 
bility of  the  vessels.  In  these  cases  it  is  a  wise 
precaution  to   determine   the  blood  pressure  by 

14 


Examination  15 

moans  of  the  sphygnomanometer,  particularly  if 
nitrous  oxide  is  to  be  administered.  The  author 
would  refuse  the  administration  of  N20  if  the 
blood  pressure  is  above  180  mm.  H  . 

Tuberculosis  is  often  written  upon  a  patient's 
face,  and  if  pulmonary,  the  breathing  may  be  the 
tell-tale.  The  respiration  should  be  noted;  a  pa- 
tient who  is  coughing  is  a  poor  subject  for  anaes- 
thesia. The  diabetic  can  often  be  recognized  by 
the  odor  of  his  breath. 

The  short,  jerky  movements  and  snappy  speech 
of  the  neurotic  are  easily  differentiated  from  the 
slow  motions  of  the  plethoric.  By  carefully  ob- 
serving a  swollen  face  one  can  often  tell  the  of- 
fending tooth;  a  necrosis  can  frequently  be  de- 
tected by  its  odor.  The  different  types  of  physi- 
cal make-up  will  not  obviate  a  necessary  operation, 
but  will  modify  our  methods  in  some  cases.  An 
hysterical  patient  is  better  fit  for  a  general  than 
for  a  local  anaesthetic.  A  keen  diagnostician 
should  always  use  all  his  senses,  be  he  a  physician, 
a  surgeon  or  a  dentist.  Everything  should  be 
noted  about  our  patients:  their  appearance,  walk, 
mannerisms,  speech,  motions,  every  little  detail; 
this  is  important  in  surgical  practice,  as  surgical 
shock  plays  a  decided  role  in  the  ultimate  success 
and  may  prove  an  important  factor  in  the  extrac- 
tion of  teeth,  especially  as  some  extractions  are 
severe  surgical  procedures. 


16  Tooth  Extraction 

In  female  patients  who  are  pregnant  the  ad- 
visability of  tooth  extraction  is  frequently  ques- 
tioned. The  author  sums  up  this  much-mooted 
question  as  follows:  Pregnancy  should  never 
stand  in  the  way  of  a  necessary  tooth  extraction. 
It  is  far  better  for  the  patient  to  be  promptly  re- 
lieved of  suffering  than  to  subject  her  to  constant 
pain,  which  is  a  much  greater  shock,  as  it  is  con- 
tinuous, and  therefore  accumulative.  The  care- 
ful extraction  of  the  diseased  tooth  can  be  clone 
with  comparatively  little  shock,  especially  if  the 
patient  is  given  an  anaesthetic,  preceded  by  a 
sedative.  The  author  has  performed  tooth  extrac- 
tion upon  women  in  all  stages  of  pregnancy  and 
has  no  ill  results  to  report. 

This  close  observation  of  the  patient  enables  the 
dentist  to  better  appreciate  the  physical  state  of 
his  charge,  to  cooperate  with  the  physician,  if 
necessary,  and  to  better  judge  the  use  of  anaes- 
thetics. 

It  is  wrong  to  make  up  your  mind  to  examine  a 
single  tooth.  First  study  the  mouth  as  a  whole; 
note  all  the  teeth  and  the  articulation.  Examine 
the  mucous  membrane,  as  to  color  and  the  pres- 
ence of  any  lesion  upon  the  lips,  the  cheeks  or 
tongue.  Be  on  the  lookout  for  any  so-called 
"fever-sores."  Make  it  your  business  to  become 
acquainted  with  a  typical  chancre.  Look  behind 
the  third  molar,  and  take  notice  of  the  pharynx 


Examination 


17 


and  the  tonsils ;  study  the  character  of  the  alveo- 
lar process,  and  then,  lastly,  examine  the  tooth  to 
be  extracted. 


Fig.  1 
Examining  the  Submaxillary  and  Sublingual  Glands 

If  there  is  swelling  or  suppuration  present,  ex- 
amine the  adjacent  glands.  (Fig.  1.) 

Avoid  placing  the  fingers  into  the  patient's 
mouth  as  much  as  possible;  it  is  pleasanter  for 
the  patient  and  Letter  protection  for  the  operator 
to  use  retractors  (Fig.  2)  or  wooden  tongue  de- 


18  Tooth  Extraction 

pressors  (Fig.  3).  These  are  the  cleanest,  as  they 
are  cheap  enough  to  be  discarded  after  use. 


Fig.  2 
Examination  of  the  Mouth  with  Retractors 

If  a  swelling  is  present,  always  examine  the 
contour  of  the  jaws,  by  standing  behind  the  pa- 
tient and  passing  the  fingers  along  the  border  of 
the  jaw  from  the  symphysis  toward  the  angle  and 


Examination 


19 


then  upward  toward  the  temporo-maxillary  joint. 
(Fig.  4.) 
This  enables  the  operator  to  compare  the  two 


Fig.  3 
Examination  of  the  Mouth  with  Wooden  Tongue  Depressors 


halves  of  the  jaw  and  also  determine  the  nature 
of  the  swelling;  whether  it  is  a  bony  tumor  or 
oedema  of  the  sofl  parts,  and  whether  or  not  there 
is  fluctuation  present. 

It'  pus  is  suspected  the  mere  extraction  of  the 


20  Tooth  Extraction 

tooth  may  not  give  sufficient  drainage  and  the 
knife  will  be  required. 

The  fever  thermometer  and  the  frequency  of  the 
pulse  will  help  to  give  the  operator  an  idea  to  what 


Fig.  4 
Examining  the  Contour  of  the  Lower  Jaw 

extent  the  organism  is  taxed  in  fighting  an  infec- 
tion. If  septic  material  is  absorbed,  the  patient's 
face  assumes  a  grayish,  pasty  appearance,  and  he 
usually  complains  of  having  had  chills.  The  ex- 
traction of  the  guilty  tooth  is  then  only  part  of 
the  treatment,  and  besides  the  establishment  of 


Previous  History  21 

thorough  drainage,  the  elimination  of  septic  ma- 
terial must  be  accomplished  by  means  of  cathar- 
tics and  the  free  imbibing  of  water. 

Before  operating,  the  patient's  previous  history 
as  to  hemorrhage  should  be  elicited  to  bring  out 
the  possible  presence  of  hemophilia. 

If  a  number  of  teeth  or  roots  are  to  be  extracted, 
it  is  always  best  to  first  make  a  chart  of  these, 
to  be  certain  that  nothing  is  overlooked  or  for- 
gotten. 


V 

Preparation  of  the  Patient 

The  successful  outcome  of  any  operation  depends 
to  a  large  extent  upon  the  physical  and  mental 
state  of  the  patient.  No  operation  fills  the  pa- 
tients with  more  apprehension  than  the  extraction 
of  teeth.  One  reason  for  this  is  the  fact  that  the 
patient  is  not  able  to  see  what  is  going  on.  The 
greater  the  fear  felt  by  the  patient  the  greater  the 
shock  to  the  nervous  system.  The  extent  of  shock 
attending  dental  operations  is  very  much  under- 
rated and  is  only  visible  to  the  careful  observer. 
The  sudden  blanching  of  the  patient,  the  frequent 
and  thready  pulse,  muscular  spasms  and  vomiting 
are  all  symptoms  of  profound  shock.  Many  pa- 
tients are  sent  home  from  the  dental  office  who 
are  really  not  fit  to  leave  it.  A  good  deal  can  be 
done  to  alleviate  shock. 

The  patient  should  be  in  a  comfortable  semi- 
reclining  position;  tight  clothing  should  be 
loosened,  whether  an  anaesthetic  is  used  or  not; 
the  head  should  be  well  supported  and  comforta- 
ble, so  that  the  muscles  of  the  neck  are  not 
strained.  The  attendant  should  always  direct  the 
patient  to  the  toilet,  as  involuntary  micturition  is 
not  only  very  embarrassing,  but  may  prove  harm- 

22 


Preparation  of  Patient  23 

ful  to  the  patient,  particularly  in  cold  weather, 
for  sudden  chilling  of  the  pelvis  as  the  result  of 
wet  clothing  may  be  the  cause  of  severe  illness. 
Many  patients  are  so  agitated  as  to  become  hys- 
terical. They  tremble  and  their  muscles  twitch. 
This  type  can  be  greatly  benefited  by  the  adminis- 
tration of  sedatives,  in  the  shape  of  bromides  or 
valerian  half  an  hour  before  operating.  The  au- 
thor has  been  having  very  satisfactory  results  by 
the  administration  of  Bromural  in  ten-grain  doses. 
In  extreme  cases  opiates  will  be  of  great  benefit. 
The  latter  should,  of  course,  only  be  resorted  to 
in  extreme  cases. 

There  should  be  as  little  preparation  as  possi- 
ble while  the  patient  is  in  the  room;  everything 
should  be  ready  when  he  enters  the  chair, 

To  prepare  the  mouth  for  any  operation  it 
would  be  wise  to  have  the  patient  carefully  brush 
the  teeth  and  use  an  antiseptic  wash,  but  this  will 
not  be  carried  out  even  under  ideal  conditions. 
The  writer  applies  the  official  Tr.  Iodine  full 
st  length  to  the  tooth  and  surrounding  structures 
before  applying  the  forceps.  It  is  true  the  buccal 
tissues  cannot  be  sterilized,  and  they  are  not  as 
susceptible  to  infection  as  other  structures,  but 
we  musl  remember  that  by  extracting  we  create 
an  open  wound,  which  may  become  an  avenue  for 
infection. 


VI 

Indications  for  Tooth  Extraction 

1.  Teeth  resisting  medicinal  or  surgical  treatment. 

2.  Teeth  causing  infection,  where  the  septic  focus 

must  be  removed  hastily. 
3  Teeth  which  have  lost  their  function. 

a.  Teeth  which  interfere  with  proper  articu- 

lation ; 

b.  Teeth  which  cannot  be  restored  by  fill- 

ings, inlays  or  crowns ; 

c.  Teeth  which  interfere  with  the  introduc- 

tion of  bridges  or  dentures. 

4.  Teeth  which  are  impacted  and  are  the  source  of 

trouble. 

5.  Supernumerary  teeth. 

6.  Teeth  which  erupt  before  or  shortly  after  birth. 

7.  Temporary  teeth  which  are  retained  beyond 

their  proper  time  of  exfoliation. 

8.  Single  teeth  in  the  upper  jaw. 

Malposed  teeth  should  never  be  extracted  for 
the  correction  of  a  deformity,  unless  an  ortho- 
dentist  has  been  consulted,  even  if  the  patient  ex- 
presses such  a  desire. 

Broken  down  temporary  teeth  should  not  be  ex- 
tracted, unless  the  seat  of  infection  and  beyond 
treatment.  It  is  often  advisable  to  retain  tem- 
porary roots  in  position  until  the  permanent  teeth 

24 


Examination  of  Tooth  25 

are  "due,"  even  if  they  cannot  be  filled  lege  artis ; 
the  fact  must  be  borne  in  mind  that  such  roots 
are  not  absorbed. 

Too  much  stress  cannot  be  laid  upon  these  " ex- 
traction-don 'ts,"  as  many  irregularities  of  the 
permanent  teeth  are  the  result  of  untimely  re- 
moval of  their  temporary  predecessors. 

Once  it  has  been  decided  upon  that  a  tooth  be 
extracted,  the  operator  should  carefully  examine 
the  diseased  organ  and  note  its  surroundings,  note 
the  thickness  of  the  alveolus,  the  possible  direc- 
tion of  the  roots,  the  degree  of  attachment,  the 
position  of  the  neighboring  teeth.  Note  whether 
or  not  the  offending  organ  is  filled  and  how.  If 
there  is  a  cotton  dressing  in  the  tooth,  remove 
same  to  note  whether  or  not  the  pulp  chamber  is 
open,  or  perforated,  also  if  the  tooth  is  split,  a 
fact  which  may  escape  notice  during  a  casual  ex- 
amination. 

In  root  extractions  the  gingival  border  should 
be  carefully  examined,  and  it  should  be  noted  if 
the  gum  tissues  cover  or  grow  into  the  same. 
Such  growths  should  be  removed  before  extract- 
ing. The  resulting  hemorrhage  can  be  controlled 
by  Tr.  Iodine  or  Trichloracetic  acid.  The  consis- 
tency of  the  root,  whether  it  is  soft  and  mushy  or 
hard,  should  be  noted.  Most  failures  in  extract- 
in-  are  due  to  hick  of  thorough  examination  be- 
fore applying  the  forceps. 


VII 

The  Armamentarium 

One  of  the  errors  committed  by  many  young  prac- 
titioners is  the  purchasing  of  too  many  forceps; 
many  a  pair  of  these  after  an  idle  life  in  the  cabi- 
net finds  a  more  active  sphere  in  the  laboratory 
loosening  flask-bolts  or  doing  some  other  "non- 
surgical" duty.  There  are  many  types  of  forceps 
for  different  teeth,  but  the  fewer  forceps  an  opera- 
tor gets  along  with  the  better.  There  are  indi- 
vidual forceps  made  for  nearly  every  tooth,  and 
almost  all  manufacturers  have  differently  shaped 
instruments,  so  that  there  exists  really  an  "em- 
barasse  de  richesse,"  which,  to  say  the  least,  to 
the  inexperienced  operator  is  confusing.  The 
writer  uses  comparatively  few  instruments,  em- 
ploying the  following  forceps,  made  by  the  S.  S. 
White  Dental  Mfg.  Co.  (Figs.  5-12) : 


26 


Armamentarium 


'K 


For  Upper  Molars,  No.  10;  for  all  other  upper 
teeth,  No.  32 ;  for  narrow,  slender  upper  roots,  No. 
65. 


Fig. 


For  all  Lower  Molars,  No.  15;  for  all  other 
lower  teeth,  No.  85;  for  lower  teeth  in  children, 
No.  101. 


Fig.  G 


Forceps  use* I  for  all  Lower  Molars  on  both 
sides,  it*  pulpal  floor  is  intact,  i.e.,  if  the  roots  are 
not  separated. 


Tooth  Extraction 


Fig.  7 

Forceps  used  for  all  lower  teeth,  except  for 
molars  whose  pulpal  floor  is  intact;  if  roots  are 
separated,  then  these  forceps  are  to  be  used.  Some 
operators  use  these  forceps  for  all  lower  molars, 
but  the  writer  prefers  the  No.  15  if  the  pulpal  floor 
is  intact,  as  it  gives  a  better  hold  on  the  tooth. 

Forceps  used  for  the  extractions  of  lower  chil- 
dren's teeth,  No.  101. 


For  the  removal  of  upper  narrow  roots,  par- 
ticularly slender  lateral  roots,  No.  65. 


Fig.  9 


Armamentarium 


2!) 


The  root  forceps  devised  by  Prof.  Cryer,  No. 
150  and  No.  151,  Figs.  10  and  11,  prove  useful; 
No.  150,  originally  designed  for  upper  roots,  fre- 
quently is  the  instrument  of  choice  for  the  re- 
moval of  third  molars  in  either  jaw. 

Oyer's  forceps  have  to  be  used  with  care,  as 
they  are  very  sharp,  and  if  applied  with  too  much 
force  they  are  apt  to  Fracture  the  crown. 


No  150 

Fig.  10 

Upper  Uoot  Forceps  After  Cryer 


Fig.  11 
Lower  Root  Forceps  After  Cryer 

One  advantage  of  the  lower  Cryer  forceps  is  the 
sharp  angle  of  the  beaks. 

A  pair  of  universal  root  forceps  applicable  in 


Fig.  12 


30 


Tooth  Extraction" 


both  upper  and  lower  jaw,  also  very  handy  for  the 
removal  of  third  molars,  are  the  No.  63. 

Besides  the  aforementioned,  the  following  in- 
struments are  required : 

Mouth  mirrors,  these  should  be  "boilable," 

Explorers  and  probes. 

Good  medium-sized  scalpels  to  incise  abscesses 
(Fig.  13). 


Fig.  13 

A  knife  to  prepare  gum  flaps. 


Fig.  14 
Lederer's  Flap  Knife* 


Fig.  15 

Shears,  both  straight  and  curved,  to  divide  soft 
tissue.  (Fig.  15.) 

A  good  water  syringe. 

*Obtainable  at  any  Dental  Depot. 


Armamentarium 


31 


Mouth  Props  of  various  size,  of  metal,  rubber 
or  wood.  A  large  variety  can  be  easily  cast  in 
lead  or  tin.  Each  prop  should  be  attached  to  a 
heavy  silk  or  cotton  string  and  tied  to  a  second 
prop,  so  that  it  can  be  withdrawn  from  the  mouth 
if  it  should  become  loosened,  and  that  there  is  no 
danger  of  the  prop  entering  the  pharynx.  The 
writer  has  two  mouth  props  connected  by  metal 
chains  (Fig.  16). 


f$/X^ 


Fig.  16 

Several  pair  of  anatomical  forceps  for  grasping- 
soft  tissue.  (Fig.  17.) 


Fig.  17 


32  Tooth  Extraction 

A  mouth  gag  and  oral  screw  should  always  be 
handy,  to  enable  the  operator  to  open  the  patient's 
mouth  while  under  an  anaesthetic. 

The  Denhart  pattern  of  mouth  gag  is  very  use- 
ful and  is  handy  to  keep  the  mouths  of  children 
open  if  the  little  patients  are  inclined  to  resist. 


Fig.  18 
Denhart  Mouth  Gag- 
Children  are  apt  to  give  the  dentist  a  good  deal 
of  trouble.  After  coaxing,  begging  and  promising 
the  fulfilment  of  their  most  coveted  wishes,  or  by 
threat  or  force,  the  little  sufferer  is  made  to  sit 
in  the  operating  chair.  The  doctor  by  coaxing 
locates  the  guilty  organ  and  takes  up  his  forceps 
to  extract,  but,  quick  as  a  flash,  the  little  fellow 
shuts  his  mouth  and  refuses  to  part  his  lips.  This 
is  a  most  trying  moment  for  both  operator  and 
parents.  In  these  instances  the  Denhart  gag 
proves  invaluable.  By  closing  the  little  patient's 
nostrils,  air  is  cut  off  and  he  is  forced  to  open 
his  mouth  a  bit.  If  the  Denhart  gag  is  now 
quickly  brought  between  the  teeth,  pressure  upon 


An  MAME  N  T  ARIUM 


33 


the  handles  of  the  instrument  will  pry  the  jaws 
apart,  and,  nolens  volens,  the  forceps  can  be  ap- 
plied. Great  care  must  be  exercised  that  the  in- 
strument is  not  opened  too  wide  for  children,  and 
that  the  soft  parts  of  the  mouth  are  not  injured ; 
the  instrument  should  never  be  opened  unless  it  is 
placed  between  the  upper  and  lower  teeth,  as 
otherwise  the  soft  tissues  will  be  traumatized. 

Another  instrument  very  useful  in  treating 
children  is  a  metal  finger  protector,  which  slides 
over  the  operator's  left  index  finger  and  is  placed 
into  the  patient's  mouth.  It  protects  the  opera- 
tor against  being  bitten  by  the  little  one,  and 
being  of  metal,  it  keeps  the  jawrs  apart. 


Fig.  19 
Metal  Finger  Protector 


Fig.  20.   Oku.  Screw 


34  Tooth  Extraction 

A  pair  of  tongue  forceps  in  case  the  tongue 
should  fall  back. 


Tongue  Forceps 


Chisels  for  cutting  bone,  as  well  as  a  mallet  and 
a  set  of  retractors  for  retracting  the  lips,  cheeks 
and  tissue  flaps.  Periosteal  elevators  to  raise  soft 
tissues  and  periosteum.  (Figs.  22-23.) 


Fig.  22 

Retractors  1,  2,  3.  4.  7,  8,  for  Lips  and  Cheeks. 


Armamentarium 


35 


Fig.  23 

1.  2.  Chisels  with  Curved  Cutting  Edge.  3.  with  Straight  Cut- 
ting Edge.  4.  5.  for  Cutting  Out  Molars.  A.  B.  C.  Periosteal 
Elevators. 


Fig.  24 
A  Powder  Blower  for  Orthoform  or  Iodoform. 


A  good  headlight  is  a  very  necessary  requisite; 
the  ample  illumination  of  the  oral  cavity  is  essen- 
tial, and  at  times  proves  very  difficult  without  the 
lamp  (Fig.  25). 


36 


Tooth  Exteaction 


Fig.  25.    Headlight 

A  cautery  operated  by  electricity  or  benzine. 


Armamentarium 


61 


Fig.  2G 


A  pair  of  bone-cutting  forceps  (Rongeur)  to  cut 
away  sharp  edges  of  bone.  (Fig.  26.) 


Fig.  27 


o 


o 

A  good  double-end  curette  to  remove  granula- 
tions and  soft  bone  tissue.  (Fig.  27.) 

Mastoid  curettes  are  also  quite  useful. 

Dressings 

Iodoform  gauze  in  strips  one-half  and  one  inch 
wide  for  packing. 

Plain  sterile  gauze. 

Gauze  bandages  two  and  one-half  inches  wide. 

Rubber  tissue. 

Cotton  swabs. 

These  are  best  made  by  winding  a  little  cotton 
around  one  end  of  a  toothpick. 

Adhesive  plaster  strips  one-half  to  one  inch 
wide. 

Cheese-cloth  sponges;  these  can  be  made  at 
home,  as  shown  in  Fig.  28. 


38 


Tooth  Extkaction 


^.. 

/ 

"  s 

' 

*> 

\ 

s 

,'' 

-         ">/ 

JjM  cJ.ih-1  Aifcd-  J***4  -         ^otd-  *in'l 


Fig.  28 

They  are  made  by  cutting  cheese  cloth  into 
pieces  one  and  one -half  inches  square,  and  fold- 
ing over  the  four  corners;  the  resulting  corners 
are  folded  over  again,  and  the  new  corners  formed 
A.B.C.D.,  are  drawn  together  by  a  strong  thread, 
the  tampon  thus  forming  a  ball.  A  number  of 
these  are  made  on  one  thread  and  then  cut  apart. 

The  following  drugs  should  be  handy : 

Hypodermic  tablets. 

Strychnine  Sulphate,  gr.  1/60. 

Morphine  Sulphate,  gr.  1/8. 

Morphine  Sulphate,  gr.  1/8,  and  Atropine  Sul- 
phate, gr.  1/150. 

Aromatic  Spirits  of  Ammonia  (Aromatic  Am- 
monia, Vaparole,  Burrows  Welcome). 


Drugs  39 

Amylnitrite  in  globules  (glass  pearls  holding  3 
and  5  minims,  which  are  broken  in  a  napkin  and 
inhaled  by  the  patient). 

Bromides.  Bromural  (Knoll  &  Co.),  five-grain 
tablets. 

Adrenalin  chloride  1 :  1000. 

Iodoform  powder. 

Orthoform. 

Novocain. 

Thiersch  Solution. 

Saline  Solution. 

Burrows  Solution. 

Boric  Acid  Solution,  2  per  cent. 

Iodine. 

Alcohol. 

Bicarbonate  of  Soda. 

Hydrogen  Peroxide. 

Nitrate  of  Silver  in  5  per  cent.  Solution. 

Nitrate  of  Silver  in  Crystals. 

Carbolic  Acid. 

Lysol. 

A  tube  of  Ethyl  Chloride. 

A  jar  of  331/2  per  cent  Calomel  Ointment. 

A  jar  of  5  per  cent.  Ichthyol  Ointment. 

A  jar  of  10  per  cent.  Ichthyol  Ointment. 

A  jar  of  Vaseline. 


VIII 

Classification  of  Cases 

Tooth  extractions  can  be  divided  into : 

1.  Normal  extractions. 

2.  The  removal  of  roots. 

3.  The  removal  of  impacted  teeth. 

4.  The  removal  of  unerupted  teeth. 

A  normal  extraction  is  one  performed  upon  a 
tooth  which  has  sufficient  crown  structure  present 
to  enable  the  operator  to  grasp  the  tooth  with  for- 
ceps and  remove  it  without  difficulty. 

Root  Extractions  are  subdivided  into: 

Normal  and  surgical.    . 

A  normal  root  extraction  is  one  performed  upon 
a  root  which  can  be  grasped  by  forceps  (or  luxated 
by  an  elevator)  and  removed  without  difficulty. 

A  surgical  root  extraction  is  an  operation  in 
which  the  knife,  chisel  or  burr  must  be  employed 
to  remove  overlying  tissue  when  extracting  a 
root;  these  are  distinctly  surgical  procedures  and 
must  be  carried  out  accordingly,  observing  strict 
asepsis  and  subsequent  proper  after-treatment  of 
the  wound. 

Impacted  teeth  are  designated  as  such  when  en- 
gaged or  incarcerated  by  adjoining  teeth  or  con- 

40 


Types  of  Cases 


41 


tiguous  structures,  as  the  ramus  of  the  mandible 
or  the  tuberosity  of  the  upper  jaw. 

Unerupted  teeth  are  such  when  covered  by  soft 
or  hard  tissue  or  both. 

These  different  types  of  operations  demand  a 
varying  technique;  nevertheless,  all  extractions 
are  governed  by  principles,  based  upon  physical 
laws,  which  demand  observation. 


Fig.  29 


Illustrating  the  Various  Types  of  Extraction  Diagrammatically 
formal   Extraction;   b,   Normal  Root;  e,  Fractured  Root-  d 
impacted  Tooth;  e.  Unerupted  Tooth 


;  d, 


IX 

The  Technique  of  Normal  Tooth  Extraction 

For  convenience  in  teaching,  the  writer  divides 
the  operation  of  tooth  extraction  into  four  stages : 

1.  The  grasping  of  the  forceps. 

2.  The  application  of  the  instrument. 

3.  The  closing  of  the  instrument  about  the  tooth. 

4.  The  actual  removal  of  the  tooth  or  root. 

It  is  important  for  the  student  to  carefully  mas- 
ter these  different  steps,  and  though  no  rigid  rules 
can  be  laid  down  for  the  extraction  of  teeth,  the 
various  steps  must  be  executed  correctly,  as  they 
depend  upon  physical  laivs,  and  these  must  be  ob- 
served if  success  is  to  be  attained. 

The   forceps    should   be    grasped   and   placed 


Fig.  30 
Placing  the  Forceps  Loosely  Across  the  Hand 

42 


Nor  mm-  Extractions 


43 


loosely  across  the  hand,  as  shown  in  Fig.  30.  The 
instrument  should  not  be  grasped  tightly,  as  ease 
of  manipulation  and  control  over  the  instrument 
are  lost,  both  of  which  are  necessary  for  a  success- 
ful operation. 

In  holding  upper  forceps,  the  fingers  are  now 
curved  about  the  handles,  the  index  finger  being 
placed  between  the  same.  The  index  finger  is 
slightly  extended  and  the  forceps  are  thus  opened 
(Fig.  31).  The  other  fingers,  curved  about  the 
handles,  prevent  the  forceps  from  opening  too  far. 


Fig.  :5l 
Bringing  the  index  Finger  Between  the  Handles,  Thus  Opening 
the  Forceps,  the  '■'>.  4.  f>  Finger  Being  Curved  About  the  Handle. 

The  hand  is  now  rotated  and  the  beaks  applied 
bucco  palatally  to  the  cervical  portion  of  the  tooth, 
pointing  the  distal  part  of  the  instrument  away 
from  the  median  line  (Figs.  32,  33,  34). 


44 


Tooth  Extkaction 


\uve 


Fig.  32 
Application  of  Beaks  to  Tooth  That  the  Distal  Part  of  Instru- 
ments Points  Away  from  Median  Line. 


Fig.  33 
Application  of  Forceps  to  Crown  of  Tooth 


Application  of  Forceps 


45 


Fig.  34 
Closing   Forceps   About   Tooth.     The   Index    Finger   Has    Been 
Withdrawn    from    Between   the   Forceps   Handles   and   Has   Been 
Curved  About  the  Instrument. 

The  forceps  are  so  adjusted  that  the  long  axis 
of  the  beaks  runs  parallel  with  the  long  axis  of 
the  root. 

This  constitutes  the  second  stage  of  the  opera- 
tion and  is  one  of  the  steps  important  to  be  ob- 
served. If  the  forceps  are  applied  incorrectly,  the 
force  used  first  in  driving  tin-  forceps  home  and 
then  in  extracting  the  tooth  will  travel  in  a  wrong 
direction  and  frequently  cause  the  tooth  to  frac- 
ture or  produce  unnecessary  mutilations  or  both. 

Fig.  35  represents  a  pair  of  forceps  correctly 
applied  to  a  Left  Upper  Canine. 


46 


Tooth  Exteaction 


E.F.  indicates  the  long  axis  of  both  the  tooth 
the  forceps-beaks ;  it  also  shows  the  path  in  which 
the  force,  requisite  to  drive  the  instrument  home 
and  to  extract  the  tooth,  will  travel. 

A.B.D.C.  is  a  rectangle  which  represents  dia- 
grammatically  the  area  or  amount  of  resistance 
offered  to  the  operator. 

2.  represents  the  same  forceps  applied  incor- 
rectly. 

c.d.  represents  the  long  axis  of  the  tooth. 

H.G.  represents  the  long  axis  of  the  forceps- 
beaks  (not  parallel  to  c.d.).  H.G.  also  shows  the 
path  along  which  the  applied  force  will  travel. 

I.K,L,J,  represents  the  area  or  amount  of  re- 


Application  of  Forceps  47 

sistance  to  be  overcome,  which  is  about  three  to 
four  times  greater  than  in  the  preceding  illustra- 
tion. 

The  "area  of  resistance"  is  obtained  by  mark- 
ing the  widest  cervical  portion  of  tooth  embedded 
in  bone  B.D.,  then  drawing  a  line  marking  the 
long  axis  of  the  tooth  E.F.  and  a  tangent  to  the 
apex  of  the  root  A.C.,  parallel  to  B.D.  Now  lines 
are  erected  at  B.  and  1).  parallel  to  E.F.  and  ex- 
tended upward  till  they  intersect  the  tangent 
A.C. ;  this  gives  us  A.B.D.C.  (shaded  portion)  and 
expresses  diagrammatically  the  area  of  resistance 
to  be  overcome  in  extracting  the  tooth  I. 

That  the  forceps-b^aks  are  incorrectly  applied 
to  Canine  2  is  shown  by  the  fact  that  the  long 
axis  of  the  beaks  H.G.  does  not  run  parallel  with 
c.d.,  the  long  axis  of  the  tooth;  we,  therefore,  get 
a  much  greater  "area  of  resistance"  (shaded  por- 
tion), and  the  tooth  is  apt  to  fracture  at  M.N.,  or 
in  exerting  sufficient  force  to  overcome  the  re- 
sistance  offered  by  the  solid  block  of  tissue 
K.L.J. I.  the  alveolus  will  splinter  or  other  injury 
result,  without  (in  many  cases)  the  tooth  leaving 
lie-  socket. 

The  "area  of  resistance"  may  appear  rather 
"theoretical";  the  writer,  however,  has  seen  this 
theory  demonstrated,  as  a  Pact,  in  the  mouth  in- 
numerabfe  limes;  both  in  the  lower  and  upper 
jaws,  [ts  object  is  to  impress  the  student  with 
the    importance   of   correct   forceps   application. 


48 


Tooth  Extraction 


After  the  forceps  have  been  applied  correctly,  the 
index  finger  is  withdrawn  from  between  the 
handles  and  placed  on  top  of  the  middle  finger,  the 
thumb  is  brought  around  the  handles  and  the 
beaks  closed  about  the  tooth.  (Fig.  36.)  This 
terminates  the  third  stage  of  the  operation. 


Fig.  36 

After  the  Forceps  Are  Properly  Applied  and  the  Index  Finger 
Is  Placed  on  Top  of  the  Middle  Finger,  the  Thumb  Is  Brought 
Around  the  Handle  and  the  Beaks  Closed. 


Closing  of  Forceps  49 

In  closing  the  forceps  too  much  force  should  not 
be  exerted,  as  the  tooth  will  then  be  fractured  by 
the  sharp  beaks.  The  forceps  should  be  closed 
just  tight  enough  to  join  tooth  and  forceps.  In 
fact,  we  must  look  upon  forceps  as  elongations  of 
our  fingers.  Hand,  forceps  and  tooth  must  be- 
come one  object. 

The  fourth  stage  of  the  operation,  the  actual 
removal  of  the  tooth  from  its  socket,  is  neither  a 
jerking  nor  pulling  process,  but  rather,  first,  the 
determination  of  the  direction  of  least  resistance 
by  luxation,  and  then  a  teasing  of  the  tooth  out  of 
its  socket,  by  an  inward  and  outward  motion. 

In  removing  a  tooth  from  its  alveolus  there  are 
two  forces  to  be  overcome : 

1.  The  pericemental  attachment. 

2.  The  mechanical  insertion  of  the  tooth  in  its 
socket.  The  latter  is  particularly  marked  in  multi- 
rooted teeth  and  is  well  illustrated  in  old  skulls, 
wherein  the  pericementum  is  dried  up  and  plays 
no  part  in  the  retention  of  the  teeth;  still  they  are 
retained  by  the  shape  of  their  roots,  as  a  peg  is 
held  in  a  board — by  adhesion.  Bearing  these  two 
"retentive  factors"  in  mind,  we  formulate  the 
actual  extraction  accordingly. 

The  pericemental  attachment  is  broken  up  by 
driving  the  root  into  the  socket,  then  luxating  the 
same  inward  and  outward  and  then  continuing 
this  rocking  motion  till  tactile  sense  indicates  the 


50 


Tooth  Extraction" 


direction  of  least  resistance  and  actually  teases 
the  tooth  out  of  its  socket. 

As  we  use  bayonet  forceps  for  all  upper  teeth, 
this  technique  applies  to  all  teeth  in  the  upper  jaw. 


Fig.  37 
Shows   Application   of  Forceps   to  Right   Upper  Third  Molar; 
Note  Left  Thumb  and  Index  Finger  Protecting  Soft  Parts. 


Application  of  Forceps 


51 


Fig.  38 


Show-  Application  of  Bayonet  Forceps  to  Upper  Anterior  Teeth; 
Note  Position  of  Fingers  of  Left  I  land  Protecting  Soft  Parts. 


52 


Tooth  Extbaction 


Fig.  39 
Shows  Application  of  Forceps  to  Left  Upper  Third  Molar ;  Note 
Left  Thumb  and  Index  Finger  Protecting  Soft  Parts. 

In  extracting  lower  teeth,  the  forceps  are 
grasped  and  also  placed  loosely  across  the  palm 
of  the  hand  (Fig.  40) ;  the  index  finger  is  then  in- 
troduced between  the  handles  (Fig.  41),  the  other 
fingers  being  placed  about  the  handle.  The  thumb 
is  now  extended  along  the  shank  of  the  instru- 
ment (Fig.  42)  ;  the  beaks  are  then  applied  to  the 
crown  of  the  tooth,  by  tilting  the  beaks  downward 
so  as  to  bring  them  in  a  parallel  position  with  the 
long  axis  of  the  tooth  (Fig.  43).  The  index  finger 
is  withdrawn  from  between  the  handles,  placed 
above  the  middle  finger,  and  the  thumb  is  kept 


Holding  Lower  Forceps 


53 


extended,  the  forceps  are  closed  (Fig.  44),  and 
the  tooth  luxated  and  withdrawn. 


Fie.  40 
Holding  Lower  Forceps,  First  Stage,  Placing  Instrument  Loosely 
Across  Palm  of  Hand. 


Fig.  41 
Introducing  Index  Finger  Between  Handles  to  Open  Forceps 


54 


Tooth  Extkactiojst 


Fig.  42 
Showing  Position  of  Lower  Forceps  as  They  Are  Being  Applied 
to  Tooth.     The  Index  Finger  Is   Still  Between  the  Handles,  the 
Thumb  Extended  Along  the  Shank  of  the  Instrument. 


Application  of  Forceps 


55 


Fig.  4:5 
Show-,  the  application  of  Forceps  to  a  Lower  Bicuspid.  The 
Index  Finger  I  his  Been  Withdrawn,  Placed  Above  the  Middle  Fin- 
'-"■''•  and  the  Thumb  Extended  Along  the  Shank  of  the  Instrument. 
Note  the  Parallel  Application  of  the  Beaks  to  the  Long  Axis 
of  Tooth.  & 


56  Tooth  Extraction 


Fig.  44 
Shows  Last  Stage  of  Application  of  Lower  Forceps,  the  Index 
Finger    Has    Been    Withdrawn    from    Between    the    Handles,    the 
Thumb  Is  Extended  Along  the  Shank,  the  Beaks  Are  Closed  About 
the  Crown  of  the  Tooth. 


With  lower  forceps,  where  the  handles  and 
beaks  form  an  angle,  the  handle  must  be  raised 
sufficiently  high,  that  the  beaks  become  a  continua- 
tion of  the  roots  (or  that  the  long  axis  of  the  beaks 
runs  as  nearly  parallel  to  the  long  axis  of  the 
tooth  as  possible) ;  not  observing  this  accounts  for 
many  failures. 

Lower  molar  forceps  should  be  so  applied  that 
the  pointed  portion  of  the  blades  strikes  the  bifur- 
cation of  the  roots  as  nearly  as  possible. 

The  curved  blades  of  the  lower  molar  forceps 
should  enclose  the  bifurcation  of  the  root,  and  un- 
less there  exists  an  ankylosis,  the  roots  are  badly 


Application  of  Forceps 


57 


curved  on  diverging;  there  is  little  chance  for  fail- 
ure if  the  tooth  is  properly  luxated  (Fig.  45). 

The  application  of  sudden  force  by  jerky  move- 
ments or  pulling  will  snap  off  the  crown  or  tire 
the  operator  rapidly,  cause  a  sore  hand  and  fail 
to  dislodge  the  tooth. 


Fig.  45 
Forceps  Correctly  and  Incorrectly  Applied  to  Lower  Teeth 


58 


Tooth  Extkaction 


Fig.  46 
Shows  Application  of  Forceps  to  Lower  Anterior  Teeth;  Note 
Left  Thumb  Supporting  Mandible,  and  Index  and  Second  Fingers 
Protecting  Soft  Parts. 


Fig.  47 

Shows  Application  of  Forceps  to  Left  Lower  Molar;  Note  Di- 
rection of  Beaks,  Parallel  to  Tooth,  Fingers  of  Left  Hand  Sup- 
porting Mandible  and  Protecting  Soft  Parts. 


Application  of  Forceps 


59 


The  teeth  in  the  jaws  form  an  arch,  of  which 
each  tooth  is  a  keystone,  excepting  the  last  molars. 
The  extracting  force  should,  therefore,  be  exerted 
buccally,  i.e.,  away  from  the  arch,  excepting  some- 
times in  lower  molars.  This,  however,  is  no  fixed 
rule,  each  case  being  governed  by  individual  con- 
ditions. 


Fig.  48 
Shows    Application   of    Forceps   to    Ri<_'ht   Lower   Molar;    Note 
Pingera  of  Lefl  Hand  Protecting  Soft  Parts. 


60  Tooth  Extraction 

So,  after  all,  if  all  points  necessary  for  success- 
ful tooth  extraction  are  considered,  the  operation 
is  not  merely  pulling,  but  a  complex  procedure. 
To  recapitulate  one  has  to  bear  in  mind : 

1.  Grasping  of  the  forceps,  not  tightly,  but 
loosely. 

2.  Correct  application  of  the  forceps-beaks  to 
the  tooth.  Long  axis  of  beaks,  parallel  to  long 
axis  of  the  root. 

3.  Closing  of  forceps,  not  too  tightly ;  join  hand, 
forceps  and  tooth  into  one. 

4.  Correct  application  of  force  upward  or  down- 
ward, then  in,  and  outward,  to  break  up  perice- 
mental fibres  and  thus  loosen  the  roots  in  their 
alveoli,  and  then  continue  the  in  and  outward  mo- 
tion, gaining  the  direction  of  least  resistance — then 
removing  the  tooth,  never  losing  control  over  the 
instrument. 

Having  considered  the  general  principles  of 
Normal  Extractions,  a  few  words  regarding  the 
position  of  the  operator  wil]  be  in  order. 

Different  operators  assume  various  positions 
while  extracting. 


Position  up  (Jpekatok  61 


Fig.  40 

Position  of  Operator  While  Extracting  Upper  Left  Anterior  Teeth 


62 


Tooth  Extraction 


Fig.  50 
Position  of  Operator  While  Extracting  Right  Upper  Posterior  Teeth 

The  writer  usually  stands  at  the  right  side, 
facing  his  patient,  except  while  removing  teeth 
from  the  left  side,  both  upper  and  lower  jaws, 
when  remaining  at  the  same  side  he  will  turn 
around,  so  as  to  stand  parallel  to  the  patient, 
(Figures  49-54  illustrate  this  better  than  words.) 


Position  of  Operator 


63 


The  writer  never  stands  behind  the  patient,  as 
it  is  easier  to  remove  teeth  from  the  alveoli  facing 
the  patient.  The  teeth  forming  an  arch  in  the 
jaws,  Figures  56  and  57,  will  demonstrate  that  it 
will  require  less  force  and  effort  on  the  part  of  the 
operator  to  dislodge  a  tooth  labially  or  buccally 
standing  in  front  (Fig.  57)  than  standing  behind 
the  patient  (Fig.  56),  as  the  operator  has  to  use 
his  wrist,  elbow  and  shoulder  joints  and  is  work- 
ing overhand  or  indirectly,  while  when  he  faces 
the  patient  he  works  directly  and  only  uses  his 
wrist  and  elbow. 


Fig.  ni 
Position  of  Operator  While  Extracting  Right  Lower  Posterior  Teeth 


64 


Tooth  Extkaction 


Fig.  52 
Position  of  Operator  While  Extracting  Lower  Anterior  Teeth 


Positiox  of  Operator 


oo 


Fig.  53 
Position  of  Operator  Extracting  Left  Upper  Posterior  Teeth 


66 


Tooth  Extkaction 


Fig.  54 
Position  of  Operator  Extracting  Left  Lower  Teeth    (Sometimes 
the  Writer  Will  Stand  as  in  Fig.  51). 


Fig.  55 
Standing  Behind  the  Patient 


Position  of  Operator  67 


Fig.  56 
Standing  in  Front  of  the  Patient 

Whichever  position  the  operator  may  take, 
whether  in  front,  behind  or  at  the  side  of  the  pa- 
tient, one  point  is  very  important  to  remember: 
the  mandible  of  the  patient  should  always  be  well 
supported  during  an  extraction,  as  the  force  neces- 
sary to  grasp  and  luxate  a  tooth,  projected  to  the 
temporo-maxillary  joint,  may  cause  a  subluxation, 
or  even  a  dislocation,  if  the  lower  jaw  is  not  firmly 
held  with  the  left  hand.  It  is  even  possible  to 
cause  a  fracture  of  the  condyloid  process  by  ruth- 
less extraction,  if  the  mandible  is  not  well  sup- 
ported. 


X 

The  Extkaction  of  Roots 

No  class  of  conditions  will  test  the  skill  of  the 
operator  more  severely  than  the  successful  ex- 
traction of  roots.  Those  roots  which  can  easily  be 
reached  by  forceps  or  elevator  will  not  prove  dif- 
ficult, but  roots,  fractured  below  the  level  of  the 
alveolar  process,  roots  malposed  or  curved,  may 
at  times  tax  the  utmost  skill  of  the  most  experi- 
enced operator,  and  their  successful  removal  fre- 
quently proves  to  be  more  difficult  operations  than 
many  major  surgical  procedures. 

For  the  extraction  of  upper  single  roots,  bayo- 
nets No.  32  and  No.  65  will  usually  suffice ;  in  some 
instances  No.  150  will  be  valuable.  For  the  mandi- 
ble No.  85  and  No.  151  answer  the  purpose.  Up- 
per molar  roots  united  by  pulpal  floor,  the  writer 
attempts  to  remove  in  one  operation  by  driving 
the  No.  10  forceps  between  gum  and  bone  as  high 
as  possible. 

If  necessary,  the  gum  is  separated  from  the 
alveolar  process  by  making  a  flap  on  the  facial  and 
palatine  aspects  (Fig.  58). 

If  the  roots  are  separated  they  are  treated  as 
single  roots  and  removed  with  the  narrow  bayo- 
net individually.     For  lower  molar  roots  which 

68 


Cake  of  Gum  Tissue 


69 


are  not  divided,  the  No.  15  lower  molar  forceps 
are  employed;  if  divided,  No.  85  and  No.  151  prove 
useful ;  a  fixed  rule  cannot  be  laid  down,  however, 
and  the  individual  case  must  decide  the  best  in- 
strument in  a  given  case. 


cmb  ath  cH±j 


Sin.\e  C^t  >.-tle  0 


Fig.  58 

If  a  root  is  decayed  or  fractured  below  the  level 
of  the  alveolar  border,  it  is  the  writer's  practice  to 
incise  the  gum  parallel  to  the  root  facially  and 
lingually,  and  then  force  the  instrument  between 
the  gum  and  the  bone,  cutting  through  the  alveolar 
process,  if  necessary.  When  grasping  the  root, 
never  include  the  soft  tissues  within  the  beaks  of 
the  forceps. 

To  cut  soft  tissues  with  the  forceps  is  brutal, 
unscientific,  unsurgical,  unnecessary  and  harmful 
to  the  patio/I,  for  it  is  not  cutting,  but  tearing 
1 1   ne. 

It  is  an  established  fact  that  incised  wounds  heal 


70 


Tooth  Extraction" 


by  first  intention  or  primary  union,  while  lacerated 
wounds  heal  by  granulation,  which  is  a  longer 
process;  besides,  a  lacerated  wound  becomes  in- 
fected more  often  than  an  incised  lesion.  It  is 
important  to  remember  in  the  extraction  of  roots 
that  gum  tissue  should  never  be  torn,  but  always 
incised  by  means  of  a  knife  or  scissors. 

Fig.  59  illustrates  the  correct  and  incorrect  pro- 
cedure in  these  cases. 


vOAnjm 


Fig.  59 
I.  Shows  the  First  Bicuspid  Root  in  the  Alveolus.  II.  Shows  the 
Gum  Incised.  III.  Shows  the  Appearance  of  the  Tissues  After 
Extraction  Following  Proper  Incision.  IV.  Shows  the  Appearance 
of  the  Parts  After  the  Extraction,  if  the  Operator  Does  Not  In- 
cise the  Gum  First,  but  Includes  the  Soft  Tissues  Within  the 
Blades  of  the  Forceps. 

If  the  root  is  a  molar  root  two  parallel  incisions 
can  be  made,  and  thus  a  flap  prepared,  which  is 
loosened  with  the  lower  end  of  the  flap  knife  or 
periosteal  elevator,  and  the  forceps  are  then 
driven  well  below  the  gum.    For  cutting  gum  tis- 


Elevators 


71 


sue  the  author  devised  a  knife  shaped  like  a  chisel, 
which  will  not  nick  when  brought  to  bear  upon 
bone.  The  lower  end  is  shaped  like  a  periosteal 
elevator  with  which  the  gum  flap  is  separated 
from  the  bone.  Fig.  14.  The  knife  can  be  sharp- 
ened on  an  Arkansas  stone. 

Elevators,  which  are  really  but  one  beaked 
single-handled  forceps  or  gouges,  prove  very  use- 
ful at  times,  but  must  be  employed  very  cau- 
tiously, as  a  slipping  elevator  can  do  a  great  deal 
of  harm.  The  instrument  is  held  in  the  right  hand 
and  grasped  as  short  as  possible;  the  left  hand 
should  always  protect  the  surrounding  tissues,  so 
as  to  avoid  slipping. 


Fig.  60 
Elevators  Used  by  the  Author,  The  Right  and  Left  Instruments 
Are  No.  13  and  No.  1  I.  S.  8.  White.  The  Other  Three.  European 
Instruments.  The  One  at  the  Extreme  Ri^lit  Is  I'artsch's  Elevator, 
Particularly  Adapted  for  Removal  <it  Lower  Roots.  The  One  Next 
to  This  Is  Lecluse.'s  Elevator,  ami  the  One  in  the  ('enter  Berten's 
Elevator. 


72 


Tooth  Extraction 


The  blade  of  the  instrument  is  then  forced  be- 
tween root  and  alveolus,  so  as  to  force  the  root 
out  of  its  socket.  There  are  many  types  of  eleva- 
tors, and  it  makes  really  no  difference  which  one 
is  employed,  as  long  as  the  desired  end  is  accom- 
plished, i.e.,  the  removal  of  the  root  with  no  dam- 
age to  adjacent  tissues.  The  writer  uses  the  in- 
struments shown  in  Fig.  60.  Figs.  61-65  demon- 
strate the  use  of  elevators. 


Fig.  61 
Shows  the  Manner  of  Using  an  Elevator  in  the  Upper  Jaw.  The 
Instrument  Is  Applied  to  an  Empty  Alveolus  to  Demonstrate  Its 
Use.  Note  the  Position  of  the  Thumb  of  the  Right  Hand;  the 
Same  Is  Resting  Upon  the  Palate;  this  Steadies  the  Hand  and 
Prevents  Slipping  of  the  Instrument.  The  Left  Hand  is  Employed 
to  Retract  the  Lips  and  Cheek.  The  Instrument  Is  Held  Very 
short. 


Use  of  Elevators 


73 


Fig.  62 
Elevator  Applied  to  Tooth,  Eight  Side  Lower  Jaw 

In  using  elevators  it  must  be  borne  in  mind  that 
these  instruments  are  used  as  levers,  and  consid- 
erable force  is  required  to  dislodge  a  root ;  if  such 
an  instrument  slips,  it  is  apt  to  do  considerable 
damage  to  the  patient,  as  perforating  the  cheek 
or  the  palate.  An  elevator  should  never  be  rested 
upon  or  against  an  adjoining  tooth.  It,  therefore, 
is  necessary  to  have  full  control  over  the  instru- 
ments. Soft  parts  should  always  be  drawn  out  of 
the  way. 
Cases  often  present  instances  where  the  frac- 


74 


Tooth  Extraction 


: 

B^y     *  i 

J»                   «E 

^  :■"              " 

itr               **  V 

Wk  i 

^'                         % 

| 

Fig.  63 
Employing  Elevator  to  Gouge  Out  Tooth — Left  Lower  Tooth. 
Note  Thumb  of  Right  Hand  on  Shank  of  Instrument.    Left  Hand 
Protects  Tongue,  Lip  and  Cheek  on  That  Side. 


tured  root  lies  so  deeply  embedded  in  bone  that  it 
is  impossible  to  reach  it  with  forceps  or  elevator ; 
in  these  cases  the  gum  and  periosteum  are  incised, 
so  as  to  form  a  flap,  which  is  separated  from  the 
bone  by  a  periosteal  elevator  and  held  by  a  re- 
tractor or  tenaculum,  thus  exposing  the  bone. 
The  bone  is  then  removed  with  engine  bur 
or  chisel  until  the  root  is  sufficiently  exposed 
to  enable  the  operator  to  remove  it  with 
elevator  or  forceps.    If  a  chisel  is  used,  it  is  ad- 


Use  of  Elevators 


75 


Fig.  64 
Elevator  Applied  to  Tooth  in  Left  Upper  Jaw 

vi sable  to  let  the  patient  bite  on  a  rubber  mouth 
prop,  as  this  reduces  the  shock  of  chiseling. 

In  operating  upon  cases  where  the  gum  is  to  be 
retracted  and  bone  removed,  the  great  drawback 
to  an  only  fairly  speedy  operation  is  the  incessant 
hemorrhage,  which  constantly  occludes  the  field  of 
operation.  As  many,  in  fact  most  of  these  cases, 
are  operated  under  local  anaesthesia  by  the  use  of 


76 


Tooth  Extraction 


Fig.  65 

Using  Elevator  to  Gouge  Out  Right  Upper  Root.    Note  Position 
of  Right  Index  Finger  and  Position  of  Left  Hand  and  Fingers. 


novocain  and  adrenalin,  the  vasoconstrictor  prop- 
erty of  the  last-named  drug  serves  to  good  pur- 
pose. This,  however,  is  not  sufficient  to  do  away 
with  all  the  annoyance  of  bleeding ;  constant  swab- 
bing by  an  assistant  with  sterile  gauze  sponges 
is  essential  to  keep  the  field  of  operation  suffi- 


Extraction  of  Roots 


t  i 


ciently  free  from  blood  so  that  the  operator  can 
proceed  with  any  degree  of  certainty.  These  gauze 
sponges  must  be  prepared  in  advance,  and  sev- 
eral hundred  should  always  be  on  hand  ready 
for  use.  A  few  illustrations  will  show  the  most 
common  root  extractions  and  the  methods  em- 
ployed. Fig.  66  shows  a  case  wherein  a  root  is  so 
crowded  in  the  alveolus  that  it  proved  impossible 
to  remove  it.  The  cause  of  its  resistance  to  ordi- 
nary methods  was  brought  out  by  the  radiograph. 
With  the  X-ray  in  possession,  a  flap  operation 
was  decided  upon,  and  after  burring  away  the  an- 
terior alveolar  wall  the  molar  root  was  easily  re- 
moved.    Cases  of  this  type  indicate  the  extreme 


Fig.  6G 


78  Tooth  Extkaction 

value  of  the  X-ray.    The  writer  makes  it  routine 
practice  to  demand  an  X-ray  if  a  tooth  or  root  of- 
fers resistance  to  ordinary  methods. 
The  steps  of  such  an  operation  are : 

1.  Sterilization  by  Tr.  Iodine. 

2.  Induction  of  anaesthesia. 

3.  Incision  A-B. 
Incision  C-D. 
Incision  B-D. 

4.  Loosen  flap  with  raspatory. 

5.  Retract  flap  of  gum  and  periosteum  F.  by 
means  of  retractor. 

6.  Bur  away  alveolar  process  at  G.  until  lower 
portion  of  root  is  exposed. 

7.  Extract  root  by  means  of  suitable  forceps. 

8.  Wash  out  wound  with  boric  acid,  and  be  sure 
to  remove  all  loose  spiculae  of  bone. 

9.  Blow  powdered  iodoform  into  wound. 

10.  Replace  periosteal  and  gum  flap. 

11.  Suture  into  position,  if  necessary,  or  pack 
wound. 

The  removal  of  pieces  of  molar  roots  in  the 
mandible  may  prove  a  very  delicate  operation, 
as  in  the  case  shown  in  Fig.  67;  here  the  ab- 
scessed area  was  situated  directly  above  the  infe- 
rior dental  canal;  the  whole  mandible  was  con- 
structed along  delicate  lines,  and  the  brutal 
method  of  crushing  out  the  root  might  have  re- 
sulted in : 


Extraction  of  Roots 


79 


1.  An  infection  of  the  mandibular  canal. 

2.  An  injury  of  the  Inferior  Dental  Nerve,  caus- 
ing neuralgia.  It  also  had  to  be  borne  in  mind 
that  the  mandible  in  this  region  is  very  thick,  and 
the  attempt  to  crush  out  a  root  must  necessarily 
result  in  considerable  bone  injury,  which  in  turn 
can  be  productive  of  a  periostitis  of  the  jaw,  or, 
what  is  worse,  osteomyelitis.  The  slower  method 
of  dissecting  the  soft  tissues  away,  elevating  the 
periosteum,  exposing  the  bone  and  then  carefully 
removing  the  overlying  osseous  tissue  till  the 
roots  are  exposed,  is  the  more  conservative,  safer 
and  surer  method. 


Fig.  67  Fig.  68 

Fig.  68  shows  another  class  of  cases  met  with 
not  infrequently;  the  technique  is  also  the  prepa- 
ration of  a  muco-periosteal  flap,  exposing  the 
bone  and  then  removing  sufficient  of  the  anterior 
alveolar  wall  to  enable  the  operator  to  remove  the 
root. 


XI 

The  Removal  of  Impacted  Teeth 

Teeth  are  designated  as  impacted  when  engaged 
or  incarcerated  by  adjoining  teeth  or  contiguous 
structures,  as  the  ramus  of  the  mandible  or  the 
tuberosity  of  the  upper  jaw. 


Impacted  Teeth  81 

The  successful  termination  of  these  cases  re- 
quires a  good  deal  of  judgment,  as  each  case  de- 
mands individual  treatment,  and  there  are  many 
types  and  degrees  of  impactions.  It  is  impossible 
to  classify  all  impactions,  but  we  can  divide  them 
primarily  into  two  groups  : 

1.  Those  teeth  whose  crowns  alone  are  engaged 
or  incarcerated. 

2.  Those  teeth  whose  crowns  and  roots  are  en- 
gaged or  incarcerated. 

The  first  class  of  conditions  is  usually  due  to 
rotation  of  teeth  in  their  sockets  (Fig.  69C). 

The  second  type  is  usually  caused  by  tilting  of 
teeth  or  faulty  eruptions  (Pig.  69B). 

It  is  evident  that  the  first  class  of  conditions  is 
more  easily  coped  with  than  the  second  division. 


For  example,  take  Fig.  69c.  Let  us  suppose 
that  the  second  bicuspid  were  to  be  removed.  This 
would  prove  a  difficult  extraction,  as  the  teeth 
are  crowded  and  the  tooth  is  slightly  rotated  in  its 
socket.  If  viewed  from  the  morsal  aspect,  the 
crowns  would  appear  as  in  Fig.  70. 


82 


Tooth  Extkaction 


The  forceps  applied  in  the  usual  fashion  and  force 
exerted  in  the  accepted  manner,  palatally  and  buc- 
cally,  indicated  by  arrows  (a)  and  (b),  both  ad- 
joining teeth  IB  and  1M  would  offer  resistance, 
the  molar  toward  the  palate,  the  first  bicuspid  fa- 
cially. Sufficient  force  employed  to  loosen  the 
second  bicuspid  would  also  luxate  the  molar  and 
first  bicuspid.  To  extract  the  second  bicuspid 
successfully  would  necessitate  the  loosening  of  the 


MZ#,2.  a&fS.  M&j*.i. 


Fig.  71 


Impacted  Teeth  83 

tooth  by  rotation  (arrow  c)  or  the  cutting  away 
of  the  shaded  portions  of  its  crown,  so  as  to  dis- 
engage it  from  its  neighbors.  Rotation  is  not  al- 
ways practical,  as  in  its  attempt  the  tooth  is  fre- 
quently fractured.  The  disengagement  of  this 
tooth  by  bur  or  disk  is  the  logical  procedure ;  after 
freeing  the  crown,  the  tooth  is  extracted  in  the 
usual  manner.  Sometimes  it  is  easier  to  crush  or 
amputate  the  crown  first,  particularly  if  it  is  cari- 
ous, and  then  extract  the  root. 

To  remove  the  impacted  third  molar  (Fig.  71) 
appears  easier  in  the  radiograph  than  it  proves 
in  reality.  Judging  by  the  X-ray,  it  seems  rather 
simple  to  remove  these  teeth,  say,  with  a  pair  of 
upper  Cryer  forceps,  but  we  must  not  forget  that 
on  the  skiagram  we  do  not  look  "at"  things,  but 
"through"  them.  The  motto  of  the  writer  is, 
"Never  to  operate  in  the  dark";  "Always  see 
what  you  are  doing";  and,  therefore,  he  advo- 
cates the  "Open"  or  flap  method.  Fig.  71  illus- 
trates the  operation. 

Steps  of  the  Operation 

1.  Sterilization  by  Tr.  Iodine. 

2.  Anaesthesia  (local). 

3.  Incisions  a.b.c.d.  and  b.d.  down  to  the  bone. 

4.  Loosen  gum  and  periosteum  with  raspatory. 

5.  Retract  flap  E,  exposing  bone. 


84  Tooth  Extkaction 

6.  Chisel  or  bur  sufficient  bone  away  to  expose 
enough  tooth  so  that  it  can  be  removed  with  for- 
ceps or  elevator. 

7.  Cut  away  all  rough  edges  of  bone. 

8.  Wash  out  bone  cavity  with  boric-acid  solu- 
tion to  remove  all  spiculae  of  bone. 

9.  Blow  iodoform  into  bone  cavity;  pack  with 
iodoform  gauze. 

The  bleeding,  which  proves  very  objectionable, 
is  controlled  by  the  suprarenin,  which  is  com- 
binded  with  the  local  anaesthetic  always  used  in 
these  cases  and  the  constant  swabbing  with  sterile 
tampons.  Fig.  69b  illustrates  another  type  of  im- 
paction, which  in  reality  comes  under  the  head- 
ing of  unerupted  teeth,  and  will  be  considered  in 
due  time. 

The  most  frequently  occurring  impaction  is  that 
of  third  molars,  the  lower  teeth  exceeding  the  up- 
per in  frequency. 

The  impacted  lower  third  molar  occurs  in  all 
•'shadings" — from  being  slightly  engaged  by  the 
second  molar  to  complete  incarceration  by  both 
anterior  tooth  and  ramus  of  mandible.   Fig.  72. 

The  technique  of  operation  in  its  removal 
varies  with  each  case.  One  factor,  however,  should 
never  be  overlooked,  and  that  is  the  radiograph. 
By  the  X-ray  alone  we  can  determine  with  any 
degree  of  accuracy  what  condition  confronts  us, 
and  a  case  which  may  appear  very  difficult  will 


Impacted  Teeth 


85 


Fig.  72 


prove  to  be  rather  easy,  while  a  very  innocent- 
looking  impaction  will  reveal  its  real  character  by 
skiagram  only. 

Some  operators  advise  the  removal  of  the 
twelve-year  molar  in  lieu  of  doing  a  difficult  third 
molar  extraction.  This  the  writer  is  not  in  favor 
of,  for  the  following  reasons  : 

1.  \Ve  never  know  if  the  released  third  molar 
will  advance  into  proper  position. 

2.  The  opposing  twelve-year  molar  is  robbed  of 
its  properly  articulating  opponent. 

3.  In  many  cases  the  third  molar  is  diseased, 
and  thus  a  healthy,  useful  tooth  is  sacrificed  for 
a  diseased  organ. 

4.  The  articulation  is  spoiled. 

Some  operators  remove  both  the  twelve-year 
molar  and  the  wisdom  tooth;  this  the  writer  con- 
siders malpractice.    The  only  indication  to  a  sacri- 


86 


Tooth  Extraction 


fice  of  the  twelve-year  molar  for  a  third  molar  is 
present  in  patients  who  are  in  very  delicate  health 
and  so  debilitated  that  a  short  operation  is  im- 
perative; also  where  the  third  molar  is  in  good 
condition,  while  the  second  molar  is  diseased. 


The  operation  for  removal  of  the  impacted 
tooth  shown  in  Fig.  73  is  one  of  the  most  difficult 
impactions  which  the  oral  surgeon  is  confronted 
by.    The  technique  is  that  of  the  open-flap  opera- 


Impacted  Teeth 


87 


tion,  aided  by  removing  the  overhanging  portions 
of  ramus  by  means  of  bur  or  chisel. 


c.  shaded  portion  bone  removed 

b-  exposed  bone 

a.  mucous  flap  turned  back 

Fig.  74 


shows  actual  bone  cavity 


Fig.  75 


Fig.  74  shows  the  method  of  operation. 
Fig.  75  the  actual  loss  of  bone  tissue,  which 
is  less  in  extent  than  if  an  attempt  is  made  to 


88  Tooth  Extkaction 

"  crush  out"  a  tooth  of  this  type  or  remove  it  by 
brutal  force. 

Some  operators  object  to  the  open-flap  method 
because  they  claim  that  the  removal  of  bone  by 
drill  or  chisel  endangers  the  integrity  of  the  sec- 
ond molar.  The  writer  claims  that  the  open-flap 
method  is  the  only  reasonable  method  to  employ. 
as  the  operator  sees  what  he  is  doing.  The  opera- 
tion is  not  "an  artistic  performance"  on  paper 
alone,  but  if  carefully  and  slowly  done,  a  practical 
procedure,  if  carried  out  along  surgical  lines.  It 
is  a  delicate  operation,  but  if  a  cataract  can  be  re- 
moved without  injury  to  the  eye,  why  should  a 
tooth  not  be  freed  from  impaction?  The  writer 
always  follows  this  method  with  gratifying  re- 
sults. 

The  next  teeth  in  frequency  of  impaction  are 
the  bicuspids. 

All  impactions  can  be  overcome  by  employing 
this  method,  i.e.,  by  dissecting  away  overlying 
gum  tissue,  in  shape  of  a  flap,  which  serves  a 
double  purpose.  First,  it  conserves  the  integrity 
of  the  soft  parts,  creating  an  incised  wound ;  and, 
secondly,  the  flap  acts  as  a  protection  to  the  bone 
cavity  after  operation.  The  incisions  may  vary, 
the  flap  may  be  differently  shaped,  but  the  method 
of  procedure  is  always  the  same  where  the  roots 
of  a  tooth  are  engaged. 

Some  teeth  are  impacted  to  such  extent  that 


Impacted  Teeth 


89 


their  roots  actually  are  situated  between  those  of 
their  neighbors.  The  writer  once  operated  for 
an  impacted  canine,  erupting  lingually  in  the 
upper  jaw.  The  crown  was  freed  by  drilling  the 
palate  away  around  its  circumference  and  grasped 
with  forceps.  No  amount  of  reasonable  traction 
and  manipulation  would  free  the  tooth,  but  the 
bicuspid  showed  slight  motion. 

The  buccal  wall  was  then  opened  by  a  flap  and 
the  canine  root  was  seen  to  be  engaged  by  the 
bicuspid.  The  impacted  portion  of  the  canine  root 


A 


3 


C. 

Fig.  76 


90  Tooth  Extkaction 

was  cut  off  with  a  fissure  bur  and  the  tooth  was 
then  easily  removed  from  the  palate.  Thus  there 
was  a  canal  from  the  facial  aspect  of  the  alveolus 
right  through  the  palate.  The  canal  or  wound 
was  carefully  washed  out,  iodoform  blown  into  it, 
and  the  facial  flap  was  sutured  into  position.  The 
palatal  opening  was  packed  with  gauze.  The  final 
result  was  perfect.  Any  other  method  employed 
would  have  resulted  disastrously  as  far  as  the 
bicuspid  was  concerned. 

Fig.  76A  shows  a  right  lower  second  bicuspid, 
impacted  and  erupting  lingually.  Fig.  76B  shows 
the  root  impaction.  Fig.  76C  illustrates  the 
lingual  flap.  The  overlying  process  or  bone  was 
cut  away  with  a  bur  until  the  tooth  could  be  lux- 
ated; in  this  case  upward,  inward,  and  outward, 
and  then  removed  from  its  socket. 


XII 

The  Removal  of  Uxekupted  Teeth 

Uxerupted  teeth  are  those  covered  by  soft  or  hard 
tissue  or  both.  If  a  tooth  has  perforated  the 
alveolus  and  is  only  covered  by  gum,  a  fact  easily 
ascertained  by  the  probe,  it  is  a  simple  matter  to 


Am'Ji'oft, 


4 


«m 


Fig.  77 
91 


92  Tooth  Extraction 

remove  the  overlying  tissue  with  knife,  anatomical 
forceps  and  curved  shears.  The  simplest  method 
to  remove  such  gum  tissue  is,  after  painting  the 
part  with  Tr.  Iodine,  to  make  a  flap,  loosen  it  with 
a  periosteal  elevator,  grasp  it  with  anatomical  for- 
ceps, and  then  cut  off  the  flap  with  curved  shears 
or  a  stroke  of  the  knife.    ( See  Fig.  77. ) 

To  reach  a  tooth  that  is  covered  with  bone  is 
more  difficult,  as  the  overlying  osseous  tissue  must 
be  removed.  The  deeper  the  tooth  is  buried  in 
bone,  the  more  difficult  the  operation.  A  pro- 
cedure of  this  kind  should  never  be  attempted 
without  a  radiograph,  which  determines  the  exact 
position  of  the  tooth,  and  its  relation  to  surround- 
ing structures,  as  the  inferior  dental  canal  and 
mental  foramen  in  the  mandible  and  the  antrum 
of  Highmore  and  nasal  cavity  in  the  upper  jaw. 
It  helps  to  gauge  the  severity  of  the  operation, 
its  probable  length  of  time  and  possible  complica- 
tions. A  lower  third  molar  may  be  lodged  so  near 
the  inferior  border  of  the  mandible  that  it  may 
prove  a  much  easier  operation  to  make  an  ex- 
ternal incision  well  under  the  border  of  the  jaw 
than  to  attempt  to  remove  the  tooth  intrabuccally. 
This  is  a  rare  occurrence,  but  it  may  happen.  The 
writer  always  insists  upon  an  X-ray  before  oper- 
ating. 

The  steps  for  removal  of  an  unerupted  tooth 


Unerupted  Teeth  93 

(buried  in  bone),  which  operation  can  be  termed 
"Odontectomy"  (cutting  out  a  tooth),  are: 

1.  Sterilization  of  field  of  operation. 

a.  Thoroughly  brushing  teeth  and  washing  the 
mouth. 

b.  Painting  the  part  to  be  opened  with  Tr. 
Iodine. 

2.  Induction  of  anaesthesia. 

3.  Retraction  or  removal  of  overlying  soft 
tissues. 

4.  Removal  of  bone,  covering  the  tooth  with 
burs,  chisels  or  bone  forceps. 

5.  Removal  of  tooth. 

6.  Washing  of  wound  with  boric  acid  solution 
to  remove  spicuhe  of  bone. 

7.  Packing  or  closing  of  wound. 

The  method  of  procedure,  on  the  whole,  is  the 
same  as  followed  for  the  removal  of  impacted 
teeth,  excepting  that  in  freeing  a  tooth  completely 
embedded  in  bone  more  osseous  tissue  must  be 
removed. 

Some  teeth  are  covered  by  a  thin  shell  of  bone, 
which  is  easily  removed  with  a  bur,  as  the  case 
shown  in  Fig.  78,  where,  after  dissecting  the 
gum  away,  flap  fashion,  the  overlying  bone  was 
removed  with  a  fissure  bur  and  a  groove  cut  poste- 
rior to  the  tooth,  as  indicated  by  dotted  lines. 
The  operator  was  then  able  to  lift  the  tooth  out 
of  its  socket  quite  readily  (Fig.  78). 


94 


Tooth  Extraction 


'  ■    •.':■"      .;■; 


Fig.  78 

In  other  cases  the  procedure  is  more  compli- 
cated. Fig.  79  shows  a  supernumerary  tooth  be- 
tween two  upper  centrals,  one  of  which  was  ro- 
tated, due  to  the  presence  of  supernumerary.  In 
this  case  two  incisions,  a.b.  and  c.d.,  were  made; 


Unerupted   Teeth 


95 


these  joined  by  a  third,  b.d.,  and  the  flap  loosened 
and  retracted.  The  shaded  portion  of  bone  F. 
was  removed  with  a  fine  rongeur  and  burs  till  the 
lower  portion  of  the  tooth  s.t.  could  be  grasped 
with  narrow  forceps  and  removed. 


3. 


O. 


Vu:.   7!) 

The  wound  was  washed  out  with  boric  acid  so- 
lution, a  little  iodoform  powder  was  blown  into 
the  cavity,  the  .mini  flap  returned  to  its  original 


96  Tooth  Extraction 

position  and  tacked  down  with  a  single  silk  su- 
ture. After  five  clays  this  was  removed,  and  there 
was  no  trace  of  any  operation.  The  two  centrals 
were  not  disturbed. 

After  the  cavity  will  be  completely  filled  with 
osseous  tissue,  orthodontic  treatment  will  be  re- 
sorted to,  to  bring  the  rotated  central  into  normal 
position. 

Fig.  80  illustrates  one  of  the  most  interesting 
and  rare  cases  the  writer  has  met  with  in  his  ex- 
perience. The  patient  was  a  young  woman  who 
had  suffered  from  neuralgia  and  had  developed 
a  swollen  face,  producing  trismus.  She  consulted 
a  dentist,  who  referred  her  to  a  physician,  who 
advised  hot  poultices  and  gave  sedatives  and  coal- 
tar  preparations  to  allay  her  pain.  After  suffer- 
ing ten  days  and  consulting  several  dentists  and 
physicians,  the  writer  was  asked  to  see  the  pa- 
tient, with  one  of  the  medical  men.  The  patient 
at  that  time  was  exhausted  and  near  collapse. 
Her  face  was  swollen,  there  was  trismus,  she  had 
a  temperature  of  103,  with  a  rapid,  irregular 
pulse,  120.  Fractured  tooth,  necrosis  of  jaw,  be- 
ginning erysipelas,  were  the  varying  diagnoses. 
There  was  no  fluctuation  discernible  on  the  face. 
She  could  not  open  her  mouth,  but  the  buccal  tis- 
sues in  the  lower  molar  region  were  swollen  and 
hard  as  a  brick.  The  writer,  after  administering 
an  anaesthetic,  made  sweeping  exploratory  inci- 


Unerupted  Teeth  97 

sions  along  the  lower  jaw  where  the  swelling  was 
found,  but  could  not  reach  any  pus. 

The  patient  was  given  opiates  and  an  immedi- 
ate X-ray  demanded,  which  cleared  up  the  diag- 
nosis. An  unerupted  lower  molar  had  produced 
an  odontoma.  The  dark  mass  occupying  the 
whole  molar  region  and  reaching  almost  from  the 
border  up  to  the  gingiva  proved  a  tooth-substance 
tumor,  odontoma.  The  patient  was  removed  to 
the  hospital,  and  tooth  and  tumor  removed. 

The  operation  was  one  of  the  severest  the  writer 
ever  had  occasion  to  attend  and  lasted  nearly 
three  hours.  One  of  the  dangers  attending  was 
the  fracture  of  the  mandible,  which  showed  but 
a  very  thin  strip  of  healthy  bone  at  the  lower 
border;  but  good  fortune  attended  the  case,  and 
the  tumor  plus  tooth  were  shelled  out  without  frac- 
turing the  jaw.  The  patient  made  a  complete  re- 
covery, and  a  radiograph  taken  subsequently 
showed  a  gradual  regeneration  of  the  jaw.  There 
are  very  few  cases  of  odontoma  on  record.  If  the 
molar  tooth  were  situated  so  low  in  the  jaw  and 
there  was  no  other  complication  present,  if  it  had 
to  be  removed,  the  removal  of  the  tooth  could  be 
accomplished  by  dissecting  the  cheek  away  from 
the  mandible  and  burring  and  chiseling  away  the 
facial  wall.  In  doing  this  the  facial  artery  would 
very  likely  be  cut  and  would  have  to  be  ligated,  or 
an  external  incision  below  and  behind  the  inferior 
border  of  the  jaw  might  accomplish  the  desired 


98 


Tooth  Extraction 


Fig.  80 

end  easier.    If  the  incision  is  located  properly,  a 
scar  will  not  be  visible. 

Fig.  81  shows  an  unerupted  lower  permanent 
canine  tooth.  The  radiograph  was  taken  because 
the  patient  still  had  a  perfectly  tight  temporary 
canine  tooth  in  situ,  and  being  referred  to  the 
writer  for  an  opinion  whether  or  not  this  "baby 
tooth"  should  be  removed,  particularly  as  she 
wanted  a  bridge  put  into  the  space  shown.  The 
author  advised  a  radiograph,  and  the  retention  of 
the  temporary  tooth,  as  it  has  its  root  completely. 
Were  it  necessary  to  ever  remove  the  unerupted 
tooth,  the  author  would  dissect  the  soft  tissue 


Unerupted   Teeth 


99 


from  the  mandible,  and  "open"  the  jaw  from  its 
facial  aspect. 

Unerupted  teeth  demanding  operation,  in  the 
writer's  experience,  occur  in  frequency  as  follows : 

Most  often  in — 

1.  Molars,  mostly  third  and  more  frequently  in 
the  lower  than  in  the  upper  jaw. 

2.  Cuspids.  4.  Bicuspids. 

3.  Supernumeraries.         5.  Incisors. 


Fig.  81 


100  Tooth  Extraction 

More  often  in  the  upper  than  the  lower  jaw. 

A  good  deal  more  could  be  written  about  the 
removal  of  unerupted  teeth,  many  more  cases 
could  be  cited,  but  it  would  spell  repetition  of  pre- 
viously mentioned  matter.  The  most  important 
features  are: 

1.  The  correct  diagnosis,  which  can  in  all  cases 
be  made  by  means  of  the  radiograph. 

2.  The  skilful  removal  of  the  tooth. 

This  means  in  all  cases  the  dissection  of  soft 
tissues  and  the  removal  of  bone  until  the  tooth  is 
reached.  There  is  no  fixed  rule  how  to  obtain  this 
end;  the  writer  has  attempted,  by  showing  prac- 
tical cases,  to  illustrate  the  general  principles. 

What  must  be  borne  in  mind  are :  Asepsis,  and 
nicety  of  procedure ;  by  that  I  mean  exactness  of 
execution.  In  other  words,  do  not  hurry;  think 
while  you  work ;  speed  will  come  by  itself. 

Another  point  to  be  borne  in  mind  is  never  to 
attempt  to  operate  in  the  dark;  do  not  feel  your 
way  along;  see  what  you  are  doing.  Dissect  away 
as  much  tissue  as  possible ;  remove  all  bone  incar- 
cerating the  tooth  or  root  to  be  extracted.  An 
aseptic  operation  favors  healing  by  primary 
union,  or  granulation.  Do  not  spare  iodine,  the 
knife  or  chisel.  It  is  better  to  cut  a  little  more  tis- 
sue away  and  proceed,  than  to  do  damage,  cause 
infection,  and  let  the  general  surgeon  do  a  radical 
operation  for  periostitis  or  osteomyelitis. 


XIII 

Post  Extractive  Treatment 

The  treatment  of  alveolar  sockets  following  ex- 
tractions is  a  much  neglected  subject,  and  many 
operators  after  removing  a  diseased  tooth  con- 
sider the  case  ready  for  dismissal. 

This  is  wrong  according  to  surgical  practice; 
no  surgeon  would  think  of  creating  an  open  wound 
and  dismiss  his  patient,  trusting  to  luck  that  all 
will  remain  well. 

The  treatment  of  the  maxillary  alveoli  after 
tooth  extraction  is  that  of  open  wounds,  and  varies 
with  the  type  of  case  presented. 

After  normal  extractions,  without  complica- 
tions, the  author  simply  applies  Tr.  Iodine  into 
the  socket  and  leaves  the  case  alone.  It  is  essen- 
tial, however,  to  inspect  the  socket  the  next  day 
to  make  certain  that  no  trouble  is  arising  and 
that  there  is  no  tendency  for  the  collection  of  food 
in  the  socket. 

The  accumulation  of  food,  etc.,  may  lead  to  in- 
fection, and  should  be  guarded  against. 

The  bleeding  in  the  socket  usually  stops  spon- 
taneously, due  to  clot  formation,  and  clot  and 
alveolus  gradually  become  absorbed. 

If  drilling  or  chiseling  of  bone  is  necessary,  that 
101 


102  Tooth  Extinction 

a  larger  wound  is  created,  the  part  is  irrigated 
with  2  per  cent,  boric  acid  or  normal  saline  solu- 
tion to  remove  spiculas  of  bone,  and  powdered 
orthoform,  to  which  a  little  powdered  plain  novo- 
cain is  added,  is  blown  into  the  wound  by  means 
of  a  powder-blower,  and  a  small  strip  of  5  per 
cent,  iodoform  gauze  is  inserted  to  prevent  food 
from  entering.  If  the  wound  is  not  very  deep,  the 
gauze  can  be  omitted  after  a  few  days,  but  irriga- 
tion should  be  continued,  first  daily,  then  every 
other  day,  and  finally  about  twice  a  week  until 
the  wound  is  closed. 

If  the  wound  is  sterile  it  can  be  closed  at  once 
by  silk  sutures,  which  are  removed  after  about 
five  days,  in  which  case  the  blood  filling  the  cav- 
ity clots  and  becomes  organized. 

If  a  chronically  abscessed  tooth  is  extracted,  it 
is  essential  to  curette  the  socket  to  remove  granu- 
lations and  debris  occupying  the  apical  space.  The 
reason  for  curetting  here  is  due  to  the  fact  that 
when  a  tooth  becomes  abscessed  nature,  in  order 
to  protect  the  surrounding  tissues  and  the  organ- 
ism at  large  against  further  infection,  throws  up 
a  wall  of  connective  tissue  to  localize  the  abscess. 
If  the  tooth  causing  the  infection  is  extracted,  the 
original  cause  is  removed,  but  the  pyogenic  focus 
having  involved  the  apical  space  is  not  completely 
extirpated,  and  the  granulations  (which  contain 
pyogenic  organisms)   remaining  behind  may  act 


After  Treatment  103 

as  an  independent  new  pyogenic  focus  and  become 
the  cause,  not  only  of  reinfection,  but  be  the  start- 
ing-point of  cystic  degeneration.  It  is,  therefore, 
essential  to  remove  these  inflammatory  products 
by  the  curette  to  insure  a  complete  cure. 

After  thorough  curettage,  the  socket  is  washed 
out  with  boric  acid,  touched  with  Tr.  Iodine,  and 
inspected  the  next  day.  It  is  wise  to  see  the  case 
a  third  time  in  forty-eight  or  seventy-two  hours, 
and  if  there  is  no  indication  of  further  trouble, 
the  patient  is  dismissed  with  instruction  to 
come  back  if  any  discomfort  is  felt. 

A  little  powdered  orthoform  and  novocain 
blown  into  the  socket  will  greatly  reduce  the  like- 
lihood of  discomfort  following. 

Sharp  edges  of  bone  should  always  be  removed 
with  bone  forceps. 

Post  Extractive  Pain 

A  very  annoying  sequela  of  tooth  extraction  is 
after-pain.    This  may  be  caused  by : 

1.  Fracture  of  the  tooth  and  part  remaining  in 
the  alveolus. 

2.  Alveolitis — i.e.,  inflammation  of  the  alveolar 
socket. 

3.  Remaining  of  septic  material  in  the  socket, 
as  a  septic  granuloma  or  abscess. 

4.  Injecting  some  irritating  substance  with  lo- 
cal anaesthetic. 

5.  Septic  operation. 


104  Tooth  Extraction 

The  treatment  is  self-evident.  First  clear  the 
socket  of  pieces  of  root,  spiculse  of  alveolus  or 
products  of  suppuration,  wash  it  out  carefully 
with  a  warm  non-irritating  solution  (boric  acid  or 
normal  saline  solution),  and  make  a  paste  of 
orthoform,  to  which  a  little  plain  novocain  is 
added,  with  glycerine,  or  pack  orthoform  and  novo- 
cain powder  into  the  socket.  This  is  best  accom- 
plished by  placing  a  tampon  into  the  socket,  hav- 
ing the  powder  scooped  up  upon  a  bone  spatula, 
and  quickly  withdrawing  the  tampon  and  then 
dropping  the  powder  into  the  socket.  The  powder 
is  gently  pressed  down  by  another  tampon,  which 
is  withdrawn  again,  and  more  powder  placed  upon 
the  first  batch.  This  is  repeated  until  the  socket 
is  filled.  The  object  of  the  tampon  is  to  prevent 
the  socket  from  filling  with  blood,  which,  if  pres- 
ent, makes  it  difficult  to  pack  the  alveolus  with 
powder.  The  packing  of  the  alveolus  with  powder 
usually  terminates  all  discomfort.  In  the  upper 
jaw  the  powder  can  be  introduced  with  the  pow- 
der-blower. If  the  powder-blower  is  used,  the 
operator  should  not  permit  the  bulb  to  fill  up  with 
air  while  the  pointed  end  is  within  the  alveolus, 
as  blood  is  easily  drawn  into  the  tip  and  the  appa- 
ratus thus  clogged. 

After  using  the  powder-blower,  the  tip  should 
be  unscrewed,  sterilized  and  dried.  In  view  of 
the  fact  that  the  tip  is  made  of  rubber,  it  is  best 


Pain  After  Extracting  105 

sterilized  by  washing  in  and  blowing  alcohol 
through,  then  thoroughly  drying  and  replacing 
upon  bulb. 

The  application  of  dry  heat  will  often  give  re- 
lief. This  can  be  applied  by  making  a  meal-bag 
and  heating  in  stove,  or  wrapping  a  connected  elec- 
tric bulb  into  a  piece  of  flannel  and  holding  to  the 
face. 

Moist  heat  should  not  be  applied  externally,  as 
it  favors  suppuration.  Another  useful  adjuvant 
to  reduce  local  hyperemia  is  a  hot  footbath. 

The  hot  footbath  must  be  prescribed  as  follows : 

A  tub  is  partly  filled  with  fairly  warm  water 

and  the  feet  immersed.  Hotter  water  is  added  to 
raise  the  temperature  of  the  bath  to  the  greatest 
degree  of  tolerance.  The  feet  are  kept  in  this  hot 
water  for  5  to  10  minutes,  keeping  up  the  degree  of 
heat.  This  causes  a  dilatation  of  the  bloodvessels 
in  the  lower  extremities,  reducing  the  blood  pres- 
sure in  the  head  and  upper  part  of  the  body.  This 
accomplished,  the  feet  are  thoroughly  dried  and 
the  patient  is  put  to  bed.  It  is  essential  not  to 
walk  with  bare  feet  and  thus  cause  a  chill,  as 
anaemia  of  the  feet  and  hyperemia  of  the  upper 
part  of  the  body  will  cause  the  pain  to  return. 

Sometimes  we  have  to  resort  to  internal  medi- 
cation. Phenacetine  and  aspirine  in  doses  of  gr. 
V  each,  to  be  repeated  after  three  hours  if  neces- 
sary, or  trigemin,  gr.  V,  or  pyramidon,  gr.  iiss., 


106  Tooth  Extraction 

will  prove  of  value.     The  first  essential,  how- 
ever, is  the  clearing  of  the  socket  of  all  debris. 

After  a  difficult  extraction  sometimes  patients 
develop  an  osteitis  or  periostitis  caused  by  me- 
chanical injury  to  the  bone.  The  symptoms  are 
pain  and  marked  tenderness  to  touch,  if  the  peri- 
osteum is  involved,  attended  by  more  or  less  swell- 
ing. The  treatment  consists  of  the  application  of 
dry  heat  or  a  wet  dressing  to  the  face,  or  the  ex- 
ternal application  of  5-10  per  cent,  ichthyol  oint- 
ment, coupled  with  the  administration  of  aspirine 
and  phenacetine,  until  relief  is  obtained. 

Post  Extractive  Hemorrhage 

The  hemorrhage  following  tooth  extraction  usu- 
ally ceases  spontaneously.  If  continuing  unduly, 
it  must  be  checked. 

Hemorrhage  occurring  directly  after  an  injury 
or  operation  is  designated  as  primary,  and  the 
flow  of  blood  occurring  some  time  after  trauma- 
tism is  known  as  secondary.  In  other  words,  a 
second  flow  of  blood  after  it  has  once  stopped  is 
actually  secondary  hemorrhage. 

Hemorrhage  can  also  be  classified  according  to 
its  etiology.    Namely,  as  caused  by : 

1.  Traumatism. 

2.  Loosening  or  disintegration  of  the  primary 
clot. 


Hemorrhage  107 

3.  Sloughing-  of  a  blood  vessel. 

4.  Lack  of  coagulative  power  of  the  blood. 

The  first  type  would  constitute  primary  hemor- 
rhage, the  second  and  third  type  secondary  hem- 
orrhage, and  the  fourth  type  may  be  either  pri- 
mary or  secondary  in  character. 

Excessive  hemorrhage  following  tooth  extrac- 
tion is  caused  by,  first,  local  conditions;  second, 
systemic  conditions. 

Local  Conditions 

1.  An  unusual,  large  alveolar  vessel. 

2.  By  forcing  the  alveolar  plates  asunder  while 
extracting,  and  thus  having  a  "gaping"  vessel. 

3.  Having  a  fractured  root  in  the  socket  acting 
as  a  wedge  and  keeping  the  alveolar  plates  apart. 

4.  Injury  of  larger  vessel.  Inferior  dental 
artery  in  the  bicuspid  region. 

The  first  step  is  the  careful  irrigation  of  the 
bleeding  socket,  removing  all  traces  of  blood  clot 
which  may  partially  fill  the  same. 

The  alveolus  is  then  probed  for  fractured  root- 
ends  or  loose  pieces  of  process.  These  must  be 
removed.  The  alveolus  is  then  pressed  tightly  be- 
tween thumb  and  index  finger  to  bring  the  alveolar 
plates  together,  in  case  they  were  forced  apart  to 
any  extent  by  a  difficult  extraction;  this  is  more 
apt  to  occur  in  the  upper  jaw  than  the  mandible. 


108  Tooth  Extraction 

The  socket  is  then  tightly  plugged  with  iodoform 
gauze,  upon  which  pressure  is  exerted. 

It  is  essential  to  pack  the  gauze  to  the  very 
bottom  of  the  alveolus  and  pack  it  tightly  in  lay- 
ers. The  pressure  is  best  exerted  by  means  of  a 
pair  of  pliers  with  cotton  wound  around  them. 
If  the  pressure  must  be  continued,  a  wad  of  tightly 
rolled  cotton  can  be  placed  between  the  jaws  and 
the  patient  asked  to  bite  upon  the  same.  If  neces- 
sary, a  bandage  can  be  applied  to  keep  the  jaws 
together.  The  gauze  tampon  is  removed  after  two 
to  three  days  very  carefully,  and  to  facilitate  its 
removal  a  little  peroxide  of  hydrogen  is  dropped 
upon  the  dressing. 

If  pressure  fails  to  stop  bleeding,  a  clot  can  be 
formed  by  escarization  of  the  vessels  with  the 
thermo-or-galvano-cautery. 

Styptics  and  astringents  occupy  a  rather  ob- 
scure place  in  the  writer's  armamentarium,  as  he 
has  had  practically  no  use  for  them  in  over  thir- 
teen years  of  active  private,  dispensary  and  hospi- 
tal practice. 

Alum,  tannic  acid,  gallic  acid,  ferropyrine, 
adrenalin  are  all  recommended.  The  writer  feels 
that  if  actual,  direct  pressure  is  applied  to  the 
bleeding  surface,  the  hemorrhage  is  bound  to 
cease,  unless  an  abnormal  condition  of  the  blood, 
retarding  coagulation,  is  present;  such  being  the 
case,  this  has  to  be  corrected. 


Hemorrhage  109 

Text-books  tell  us  that  bleeding  can  be  con- 
trolled by  the  internal  administration  of  ergot  or 
tannic  acid ;  this  is  true  in  uterine  hemorrhages ; 
the  author,  however,  has  doubts  whether  an  alveo- 
lar hemorrhage  can  thus  be  controlled.  As  an  ad- 
juvant to  other  treatment  (pressure)  it  may  have 
its  value,  but  the  writer  has  never  failed  to  con- 
trol any  hemorrhage  if  no  systemic  factor  was 
at  the  bottom.  If  internal  medication  is  to  be  re- 
sorted to,  the  administration  of  calcium  lactate  is 
more  certain  in  action  (raising  the  coagulative 
power  of  the  blood)  than  giving  styptics  in- 
ternally. 

The  writer  would  warn  against  the  use  of 
Monsels'  solution,  as  the  clot  formed  by  sesqui 
chloride  of  iron  comes  away  easily  and  bleeding  is 
started  again. 

A  patient  suffering  from  severe  bleeding,  after 
having  the  socket  packed,  and  this  is  always  the 
first  consideration,  should  be  placed  at  perfect 
rest,  sitting  up  in  a  comfortable  chair,  in  a  cool 
room.  Cold  applications  to  the  jaw  wherever  the 
bleeding  takes  place  have  a  tendency  to  constrict 
the  blood  vessels. 

Systemic  Conditions 

General  systemic  conditions  of  interest  to  the 
dentist  in  the  treatment  of  post  extractive  hemor- 
rha.iv  are  mainly:  Ana-mia  and  hemophilia. 


110  Tooth  Extraction 

If  the  operator  is  careful  and  closely  observes 
his  patient  before  operating,  he  will  frequently 
note  the  pallid  appearance  of  his  patient,  though, 
of  course,  not  all  anaemics  look  pale.  However, 
the  operator  should  note  all  little  details  about 
his  patient  and  make  good  use  of  his  findings  be- 
fore he  meets  with  alarming  symptoms.  The  im- 
portant fact  to  bear  in  mind  is  that  just  as  the 
amount  of  blood  in  an  organism  is  reduced,  so  the 
coagulability  of  the  remaining  liquid  is  lessened; 
therefore,  an  anaemic  individual  should  be  treated 
with  care.  If  a  large  number  of  teeth  are  to  be 
extracted  and  the  patient  appears  very  anaemic, 
it  is  better  to  consult  the  physician,  or  if  that  is 
not  practicable,  why,  make  an  approximate 
hemoglobin  estimate  with  Talquist  hemoglobin 
scale.  It  will  give  a  fairly  accurate  idea  of  the 
hemoglobin  status  of  the  x)atient,  and  if  it  is  low 
(60  or  less)  it  is  safer  to  consult  with  the  medical 
adviser. 

It  is  better  to  err  on  the  safe  side  a  good  many 
times  than  to  fail  to  recognize  one  case  which  will 
cause  trouble.  The  operator  may  not  have  any 
trouble  but  once  in  a  lifetime ;  the  careful  operator 
should,  however,  never  meet  with  an  accident 
which  is  avoidable,  and  be  always  on  the  look- 
out. 

If  the  teeth  are  the  cause  of  infection,  of  course, 
the  septic  focus  must  be  removed  at  all  times,  but 


Hemophilia  111 

precautions   should  be   taken   to   avoid   any  un- 
toward effects. 

Hemophilia 

Is  a  condition  of  the  blood  wherein  there  is 
present  a  chemical  disturbance  which  interferes 
with  coagulation.  The  careful  operator  should 
always  bear  in  mind  the  possibility  of  his  patient 
being  a  hemophiliac  and  question  him  accordingly. 
If  the  history  of  the  patient  brings  out  that  he  suf- 
fers from  such  disturbance,  the  writer  prescribes 
calcium  lactate,  as  well  as  the  ingestion  of  albu- 
men (in  the  shape  of  as  many  raw  eggs  as  the  pa- 
tient is  able  to  take,  six  to  eight  a  day)  for  about 
thirty  hours  prior  to  extracting.  This  prophylac- 
tic treatment  has  controlled  all  excessive  hemor- 
rhage in  the  six  cases  which  the  writer  has  seen. 

Case  I:  Patient  J.  D.,  age  thirty,  pale-looking, 
delicate  young  woman,  unmarried.  Distinct  his- 
tory of  hemophilia,  bleeds  very  profusely  at  the 
slightest  injury,  menstruation  very  copious,  lasts 
about  a  week,  always  in  delicate  health.  Had  a 
molar  tooth  extracted  in  the  morning  and  bled 
quite  profusely.  Dentist  told  her  to  rinse  mouth 
with  cold  water.  Alveolar  hemorrhage  finally 
-topped  late  in  the  afternoon  and  patient  went  out 
thai  evening.  About  ten  o'clock  bleeding  started 
again.  Patient  returned  home  and  tried  several 
home  remedies;  these  failing,  a  physician  was 
summoned,  who  packed  the  alveolar  socket  with 


112  Tooth  Extraction 

adrenalin  gauze.  This  did  not  have  the  desired 
effect,  the  bleeding  continued,  and  the  patient  be- 
gan to  show  signs  of  weakness,  finally  fainting. 
The  writer  was  called  in  consultation  at  two  a.  m. 
The  patient  looked  very,  very  pale,  and  was  too 
weak  to  stand.  Her  pulse  was  rapid  and  very  thin. 
The  writer  first  cleared  out  the  socket,  broke  up 
the  alveolar  septum,  curetted  out  pieces  of  clot, 
and  then  packed  the  socket  very  tightly  with  iodo- 
form gauze,  placed  a  roll  of  cotton  between  the 
jaws  and  applied  a  bandage. 

The  patient  was  put  to  bed  and  given  morphine 
and  atropine  hypodermically,  also  twenty  grains 
of  calcium  lactate  were  administered.  Raw  eggs 
in  milk  were  ordered  every  three  hours.  The  cal- 
cium lactate  was  ordered  in  twenty-grain  doses 
every  four  hours  for  two  days ;  also  the  ingestion 
of  lots  of  water.  Patient  remained  in  bed  ten 
days.  A  tonic  containing  iron  and  strychnine  was 
given,  and  plenty  of  nourishing  food — milk,  broth, 
eggs.  There  was  a  slight  recurrence  of  hemor- 
rhage on  the  fifth  day,  when  the  packing  was  re- 
moved. Calcium  lactate  was  administered  again 
for  thirty-six  hours. 

A  year  later  the  same  patient  had  to  have  an- 
other tooth  removed.  She  consulted  the  writer. 
She  was  given  calcium  lactate  and  egg  albumen 
for  thirty  hours  prior  to  extraction,  and  there  was 
no  abnormal  hemorrhage. 


Hemophilia  113 

The  other  cases  which  the  writer  saw  were  cases 
sent  to  him  as  "hemophiliacs"  for  extraction. 
They  all  received  calcium  lactate  in  fifteen-grain 
doses  every  four  hours  until  five  or  six  doses  were 
taken,  also  albumen  in  the  shape  of  raw  eggs,  and 
they  all  did  well. 

The  following  case  is  of  interest,  showing  the 
value  of  treatment  before  extraction  in  a  negative 
way : 

Mrs.  E.  A.,  age  33,  married,  hemophiliac,  was 
referred  by  her  dentist  for  the  extraction  of  two 
small  roots.  The  patient  requested  to  have  her 
physician  present.  The  physician,  upon  arriving 
at  the  writer's  office,  sent  the  patient  from  the 
room  and  told  the  writer :  ' '  Now,  Doctor,  I  do  not 
believe  in  this  calcium  treatment;  there  will  be 
no  trouble  in  this  case  at  all;  you  just  extract 
these  roots."  The  writer  called  the  physician's 
attention  to  the  fact  that  the  patient  had  had  a 
great  deal  of  trouble  only  a  year  previous  after 
having  a  tooth  extracted  by  another  specialist. 
The  physician  insisted  upon  having  the  roots  out 
without  preliminary  treatment,  taking,  as  family 
physician,  all  responsibilities  upon  himself.  Un- 
der those  circumstances,  the  writer  yielded  and 
extracted  the  roots.  Three  days  later  the  writer 
was  summoned  late  at  night  by  the  physician  ' '  to 
do  something  to  stop  the  bleeding."  The  hemor- 
rhage was  finally  stopped  after  most  strenuous 


114  Tooth  Extkaction 

treatment,  using  the  thermo-cautery  three 
times  and  giving  several  injections  of  horse 
serum.  The  patient  was  in  bed  for  three  weeks, 
until  she  was  strong  enough  to  leave  the  city  for 
a  stay  in  the  country. 

The  damage  in  hemophiliacs  should  be  avoided 
by  treatment  before  the  extracting. 

The  treatment  if  "a  case  is  a  bleeder"  consists, 
first,  in  "cleaning  up"  the  bleeding  alveolus,  pack- 
ing it  and  administering: 

Calcium  lactate  and  egg  albumen,  as  indicated 
above. 

Rest  in  bed  and  the  general  improvement  and 
building  up  of  the  system. 

The  injection  of  horse  or  human  serum  to  raise 
the  coagulability  of  the  blood. 

If  human  or  plain  horse  serum  is  not  available, 
antidiphtheretic  serum  from  any  Board  of  Health 
Station  will  answer  the  purpose. 

The  local  application  of  horse  serum  upon  gauze 
right  into  the  bleeding  socket  has  also  proven 
valuable. 

If  a  great  deal  of  blood  has  been  lost,  the  in- 
travenous injection  of  normal  saline  or  Ringers' 
solution  is  indicated. 

Blood  transfusion  may  have  to  be  resorted  to. 
Cases  of  this  type  are  distinctly  hospital  cases, 
as  they  need  constant  watching  and  treatment 
which  cannot  be  given  at  home. 


XIV 

The  Treatment  of  Complications  Attending 
Tooth  Extraction 

Tooth  extractions  are  sometimes  attended  by  ac- 
cidents and  complications,  the  treatment  of  which 
shall  be  considered  in  this  chapter. 

1.  The  Luxation  of  Adjoining  Teeth 

The  accidentally  loosened  tooth  is  ligated  to  its 
neighbors  by  a  silk  or  wire  ligature.  The  writer 
preferably  employs  Angle's  regulating  wire,  as  a 
metallic  thread  is  not  affected  by  the  buccal  secre- 
tions and  food  as  silk  or  cotton. 

The  best  ligature  for  this  purpose  is  made  by 
including  the  luxated  tooth  and  those  teeth  which 
are  to  support  it  in  a  wire  loop  and  twist  it  fairly 
tight.  Then  pass  another  wire  between  each  in- 
terproximal space  faciolingually  under  the  first 
loop  and  bring  it  out  linguo-facially  over  the  same. 
This  interproximal  loop  is  drawn  tight.  Thus  a 
small  loop  is  passed  under  and  over  the  ligature, 
holding  all  the  teeth  between  each  interproximal 
space.  After  all  interproximal  spaces  are  wired, 
the  original  or  large  loop  is  drawn  tight.  The 
twisted  extended  portions  are  doubled  up  into  the 

115 


116 


Tooth  Extraction 


interproximal  spaces,  so  that  the  lips  are  not  trau- 
matized. They  must  not  extend  too  far  lingually, 
or  they  will  injure  the  tongue.  This  is  practically 
a  Hammond  splint.    A  few  days'  immobilization 


Fig.  82 
Showing  the  Manner  of  Tying  Wire  Splint 

will  usually  restore  these  teeth  to  normal  health, 
unless  the  pulp  is  affected,  and  then  the  treatment, 
of  course,  is  devitalization. 


2.  Accidentally  Extracted  Teeth 

can  sometimes  be  implanted.  If  a  tooth  be 
removed  accidentally,  it  is  washed  in  lukewarm 
sterile  saline  solution,  grasped  with  sterile  gauze, 
opened,  pulp  removed,  pulp  chamber  and  root 


Complications  117 

canal  thoroughly  cleansed  and  filled,  the  tooth 
filled  and  again  washed  in  saline  and  reintroduced 
into  its  socket  and  ligated  to  its  adjoining  fellows. 
It  is  evident  the  tooth  has  to  be  handled  carefully, 
and  strict  asepsis  must  be  observed.  It  is  essen- 
tial to  avoid  injury  to  the  pericementum,  so  that 
the  reimplantation  be  a  physiologic  implantation. 
If  the  peridental  membrane  is  destroyed,  the  re- 
implantation will  be  a  mechanical  implantation, 
just  as  a  porcelain  root  would  be.  A  physiologic 
implantation  has  a  better  chance  of  permanency, 
as  Kauffer,  of  New  York,  has  shown. 

The  writer  has  seen  a  few  (three  or  four)  such 
reimplanted  teeth,  having  given  satisfactory  ser- 
vice for  several  years ;  however,  he  is  very  skepti- 
cal as  to  the  final  outcome.  It  is  a  risky  thing  to 
promise  a  patient  a  good  result  with  certainty. 
It  is  worth  trying,  if  all  steps  are  carried  out 
under  absolute  asepsis. 

3.  Fracture  of  Adjoining  Teeth 

The  treatment  is,  of  course,  the  restoration  of 
the  lost  structure  by  filling,  inlay  or  artificial 
crown,  according  to  the  amount  of  tissue  lost. 

The  writer  suggests  to  wait  a  few  days  until  a 
restoration  by  filling  or  inlay  is  attempted  to  have 
an  opportunity  to  learn  whether  or  not  the  pulp 
has  been  affected  by  traumatic  shock.    It  is  awk- 


118  Tooth  Extraction 

ward  to  perform  a  restoration  and  then  be  forced 
to  open  into  the  tooth  a  little  later.  Of  course,  we 
have  to  bear  in  mind  that  a  tooth  may  not  show 
signs  of  devitalization  for  a  long  time,  sometimes 
not  for  months  or  years. 

4.  Fracture  of  Alveolus 

If  there  obtains  a  comminuted  fracture  of  the 
process  and  there  are  small  loose  pieces  discerni- 
ble, these  should  be  removed ;  otherwise  the  alveo- 
lus is  gently  pressed  "into  place,"  i.e.,  restored 
to  its  original  position  and  left  alone.  In  a  few 
days  union  will  usually  occur. 

5.  Fracture  of  the  Jaw 

A  very  rare  complication,  unless  there  exists 
necrosis,  so  that  only  a  narrow  strip  of  healthy 
bone  remains.  The  treatment  of  fractures  is  so 
well  known  that  I  shall  not  enter  into  its  discus- 
sion. A  radiograph,  however,  should  be  taken  in 
all  cases  of  fractures  of  the  teeth,  alveoli  or  jaw, 
as  the  X-ray  will  bring  out  complications  which 
may  not  be  suspected. 

6.  Opening  of  the  Antrum  of  Highwiore 

The  accidental  opening  of  the  Antrum  of  High- 
more  may  occur  during  the  extraction  of  upper 
teeth.  The  treatment  of  this  mishap  varies  with 
different  attending  conditions.    If  the  root  of  the 


Complications  119 

extracted  tooth  entered  the  maxillary  sinus  and 
there  is  no  sinus  disease  present,  it  is  best  to 
either  suture  the  opening  directly  with  silk  or  silk 
wormgut,  without  probing  or  washing,  as  infec- 
tion may  be  carried  into  the  sinus,  or  to  place  a 
piece  of  iodoform  gauze  against,  not  into,  the 
opening,  and  hold  this  in  place  by  passing  a  figure- 
of-eight  wire  ligature  around  the  adjoining  teeth. 

The  symptoms  of  breaking  into  the  antrum  are : 
First,  appearance  of  blood  through  the  naris  on 
the  same  side;  second,  forcing  air  through  the 
nose  into  the  mouth ;  third,  nasal  twang  of  speech. 

The  first  symptom  may  be  absent  if  adrenalin 
has  been  injected ;  the  last  symptom  is  rarely  pres- 
ent. The  second  sign,  however,  the  ability  to  force 
air  into  the  mouth  through  the  nose,  the  nostrils 
being  shut  with  the  fingers,  is  the  most  reliable 
sign  attending  this  accident. 

It  is  a  wise  precaution  to  have  the  patient  try 
this  if  one  is  in  doubt.  Of  course,  we  have  to  bear 
in  mind  the  possibility  of  infecting  the  antrum  if 
the  patient  is  suffering  from  "a  cold,"  as  a  large 
percentage  of  cases  of  antrum  disease  is  caused  by 
nasal  infection. 

7.  Forcing  of  a  Tooth  or  Root  into  the  Antrum 

If  a  tooth  is  forced  into  the  maxillary  sinus,  this 
is  removed  more  easily  than  a  root,  as  the  open- 
ing created  is  larger  ami  a  tooth  can  be  grasjied 


120  Tooth  Exteaction 

with  anatomical  forceps.  A  small  root  slipping 
into  the  antrum  through  a  small  opening  offers 
more  difficulty  for  its  removal.  The  proper  pro- 
cedure is  to  make  an  opening  large  enough  to  re- 
move it,  as  a  maxillary  sinusitis  will  most  likely 
result  if  the  root  is  left  in  situ.  A  radiograph  will 
facilitate  the  localization  of  the  root,  if  it  cannot 
be  reached  readily.  The  opening  should  be  made 
by  preparing  a  mucoperiosteal  flap,  i.e.,  to  dissect 
mucous  membrane  and  periosteum  away  from  the 
bone,  cut  away  sufficient  bone  to  be  able  to  remove 
the  root,  and  then  suture  the  mucoperiosteal  flap 
to  close  the  opening.  If  the  antrum  is  in  a  healthy 
state,  nothing  should  be  introduced  into  the  same 
but  normal  saline  or  2  per  cent,  boric  acid  solu- 
tion, then  the  cavity  closed. 

If  while  extracting  the  operator  enters  a  cav- 
ity, he  should  not  take  it  for  granted  that  he  is 
"in  the  antrum,"  but  bear  in  mind  the  possibility 
of  the  presence  of  a  cyst.  The  differential  diag- 
nosis depends  upon  the  following  points : 

1.  A  cyst  contains  liquid  or  semi-liquid  mate- 
rial. It  is  a  good  plan  to  wash  out  the  cavity  with 
sterile  saline  and  note  the  appearance  of  the  liquid 
returned. 

2.  A  cyst,  unless  it  has  involved  the  antrum,  will 
not  permit  passage  of  air  from  the  nose  into  the 
antrum  and  thence  into  the  mouth. 

3.  If  there  exists  a  normal  ostium  maxillare  and 


Complications  121 

liquid  is  forced  into  the  antrum,  the  same  will  flow 
from  the  nose. 

4.  The  radiograph. 

If  the  cavity  entered  proves  to  be  a  cyst,  this, 
of  course,  must  be  treated  accordingly. 

8.  Fracture  of  the  Tooth  While  Extracting 

The  question  whether  or  not  a  tooth  which  frac- 
tures while  being  extracted  should  be  permitted 
to  remain  has  been  brought  up  from  time  to  time, 
and  well-known  specialists  differ  in  their  final 
opinion. 

Primarily  the  writer  would  say  that  a  broken- 
ofr  root  should  always  be  removed;  on  the  other 
hand,  he  would  not  deem  it  wise  to  subject  a  pa- 
tient, who  is  already  suffering  from  shock,  to  a 
long  searching  operation,  which  in  the  end  is  not 
completed. 

If  a  root  fractures,  the  writer  proceeds  as  fol- 
lows :  Every  reasonable  attempt  is  made  to  re- 
move it  by  means  of  fine  forceps  and  elevators. 

These  means  may  prove  fatal  for  two  reasons : 

1.  Incessant  hemorrhage. 

2.  The  fractured  piece  may  be  so  small  that  it 
cannot  be  reached,  i.e.,  the  alveolar  socket  is  so 
deep  that  the  root  cannot  be  grasped  or  en- 
croached upon. 

If  the  hemorrhage  interferes  with  the  opera- 
tion, the  writer  packs  the  socket  with  iodoform 


122  Tooth  Extraction 

gauze  and  dismisses  the  patient.  At  the  next  visit 
the  patient  is  given  bromural,  gr.  x,  and  the  site 
injected  with  novocain  and  suprarenin,  the  tam- 
pon carefully  removed  and  the  root  taken  out  by 
cutting  away  the  overlying  tissue  with  knife  and 
chisel  or  bur,  doing  a  flap  operation. 

If  the  root  escapes  all  attempts  of  removal,  the 
patient  is  radiographed  to  ascertain  its  exact  po- 
sition, its  shape  (sometimes  crooks  or  hyperce- 
mentosis  incarcerate  it)  and  the  surrounding 
structures,  for  one  has  to  consider  the  inferior 
dental  canal,  and  mental  foramen  in  the  mandi- 
ble, and  the  antrum  and  nasal  cavity  in  the  upper 
jaw.  After  the  root  is  located  it  is  removed  by 
the  open-flap  operation. 

9.  Trismus  (Locked  Jaw) 

Swelling  about  the  face  producing  "locked" 
jaw  may  prove  a  difficult  complication  of  tooth 
extraction. 

The  infiltration  of  the  muscles  of  mastication 
caused  by  abscessed  or  impacted  lower  molars 
particularly  engages  our  attention.  This  infiltra- 
tion produces  that  swelling  "hard  as  a  board," 
locking  the  jaws  completely,  preventing  even  the 
introduction  of  a  thin  cardboard  between  the 
teeth;  or  the  patient  may  be  able  to  open  the  jaws 
more  or  less,  but  not  sufficiently  to  apply  forceps 
to  the  guilty  tooth.    The  amount  of  trismus  de- 


Complications  123 

pends  upon  the  muscles  which  are  infiltrated  and 
upon  the  stage  of  inflammation  present.  The 
writer  divides  locked  jaw  into  three  types : 

Locked  Jaw  of  the  First  Degree 
Cases  wherein  the  patient  is  able  to  open  the 
mouth  sufficiently  so  that  the  tooth  to  be  extracted 
can  be  reached  with  little  stretching. 

Locked  Jaiv  of  the  Second  Degree 
Cases  wherein  a  finger  can  be  introduced  be- 
tween the  anterior  teeth. 

Locked  Jaw  of  the  Third  Degree 

Cases  wherein  the  jaws  are  closed  completely. 

The  successful  termination  of  these  cases  try 
the  utmost  judgment  of  the  operator.  The  cardi- 
nal questions  to  ask  are : 

Is  the  patient  suffering  from  pain  and  direct  in- 
fection that  an  immediate  extraction  is  impera- 
tive? 

Is  pus  present  and  can  pus  be  reached? 

The  first  degree  of  locked  jaw  is  overcome  by 
administering  an  anaesthetic;  introducing  a  Den- 
hart  gag  and  gently  forcing  the  jaws  apart  suffi- 
ciently  to  grasp  the  diseased  tooth  with  forceps. 

The  second  degree  gives  a  little  more  concern. 
The  injudicious  stretching  of  infiltrated  muscle 
may  result  in  injury  of  this  structure  with  sub- 
cutaneous hemorrhage.    Very  undesirable  compli- 


124  Tooth  Exteaction 

cations,  causing  permanent  damage,  may  result 
(stretching  of  ligament,  tearing  of  muscles). 
There  is  danger  of  producing  severe  shock  if  a 
muscle  is  stretched  forcibly. 

In  these  cases  it  is  advisable  to  administer  seda- 
tives— bromural,  0.6  (gr.  X)  or  opiates,  morphine 
sulphate,  0.0015  (gr.  y±) — to  reduce  shock  and 
sensibility,  and  then  applying  hot  applications  to 
the  swelling  for  five  minutes,  then  introducing  an 
oval  screw  between  the  teeth  and  gradually  pro- 
duce relaxation  of  the  infiltrated  muscles.  The 
stretching  must  be  done  gradually,  and  it  is  sur- 
prising what  can  be  accomplished  with  a  little 
patience. 

The  opening  of  the  jaws  may  require  from  ten 
minutes  to  an  hour. 

After  the  jawrs  have  been  opened  sufficiently,  the 
tooth  giving  trouble  is  extracted. 

The  most  difficult  cases  to  treat  are,  of  course, 
those  of  the  third  degree.  The  method  of  pro- 
cedure is  the  same  as  outlined  for  treatment  of 
the  second  degree.  The  patient  is  given  an  opiate 
and  the  teeth  pried  apart  gradually  with  any  fine 
instrument,  so  as  to  enable  the  operator  to  intro- 
duce the  small  end  of  the  screw  gag.  This  instru- 
ment is  then  very  slowly  turned  to  gradually  force 
the  jaws  apart.  In  some  cases  it  is  impossible 
to  get  sufficient  relaxation  to  extract,  but  we  can 
open  the  jaws  far  enough  to  be  able  to  palpate  the 


Complications  125 

swelling  intrabuccally  and  incise  where  pus  is  felt 
or  suspected.  After  drainage  has  been  estab- 
lished, the  swelling  will  begin  to  go  down.  The 
treatment  after  incision  consists  in  : 

1.  The  administration  of  a  laxative. 

2.  The  local  application  of  wet  dressings  of 
either  Thiersch's  solution,  Liq.  Alumini  Acetatis, 
or  a  saturated  solution  of  Epsom  salts,  diluted 
with  four  parts  of  water. 

These  cold  applications  can  be  made  for  one 
hour  at  a  time,  three  times  a  day,  or  a  wet  dress- 
ing can  be  put  on  and  kept  there  in  situ  by  a 
bandage.  A  mouth-wash  is  to  be  used  frequently 
to  reduce  oral  sepsis. 

In  conclusion,  the  author  again  emphasizes  the 
fact  that  tooth  extractions  are  surgical  procedures 
and  must  be  carried  out  according  to  surgical 
principles.  Careful  examination  and  deliberation 
are  essential  before  extracting,  post  extractive  in- 
spection and  treatment  are  required  subsequently. 

Tooth  extractions  are  divided  into : 

1.  Normal  extractions. 

2.  Root  extractions,  \  0       •    ', 

'  |  Surgical. 

3.  Removal  of  impacted  teeth. 

4.  Removal  of  unerupted  teeth. 

Surgical  root  extractions,  as  well  as  the  re- 
moval of  impacted  and  unerupted  teeth,  are  best 


126  Tooth  Extraction 

carried  out  by  the  preparation  of  a  tissue  flap 
and  the  free  removal  of  overlying  bone  tissue. 
The  technique  in  all  cases  is : 

1.  Sterilization. 

2.  Induction  of  anaesthesia. 

3.  Preparation  of  soft  tissue  flap. 

4.  Retraction  of  flap. 

5.  Removal  of  overlying  bone  tissue. 

6.  Removal  of  root  or  tooth. 

7.  Removal  of  all  granulations  or  broken-down 
tissue. 

8.  Irrigation  of  wound  with  non-irritating  solu- 
tion. 

9.  Packing  or  closing  up  of  wound. 

10.  Subsequent  inspection  or  repacking  or  irri- 
gation of  wound,  as  case  demands. 


PART  TWO 


LOCAL  ANESTHESIA  OF  THE   MAXILLA 


I 

Anaesthesia 

General — Local — Conductive — Regional 
Anesthesia  is  the  loss  of  sensation  produced  by 
the  action  of  agents  known  as  anaesthetics. 

General  anaesthesia  is  induced  by  the  introduc- 
tion of  such  agents  into  the  circulation  which,  act- 
ing upon  certain  cerebral  centers,  produce  uncon- 
sciousness accompanied  by  complete  loss  of  sen- 
sation. 

General  anaesthetics  are  introduced  by  inhala- 
tion through  the  lungs  and  by  intravenous  or  rec- 
tal infusion.  They  are  absorbed  by  the  blood,  and 
thus  carried  to  the  brain. 

Local  anaesthesia  is  the  regional  loss  of  sensa- 
tion produced  by  the  action  of  certain  agents  upon 
sensory  nerves.  Agents  producing  local  loss  of 
sensation  are  known  as  local  anaesthetics.  Local 
anaesthesia  has  displaced  general  anaesthesia  to  a 
large  extent  in  dental  and  oral  operations. 

Local  anaesthesia  can  be  produced  by  physical 
means,  as  cold  and  pressure,  and  by  the  use  of 
drugs,  as  cocaine,  eucaine,  alypine,  novocain,  etc. 

Physical  agents  shall  not  be  considered,  but  the 

129 


130  Local  Anesthesia 

writer  shall  confine  himself  strictly  to  the  produc- 
tion of  local  anaesthesia  by  the  use  of  drugs. 

Local  anaesthesia  can  be  produced  by  three  meth- 
ods: Direct  application,  infiltration  and  "nerve 
blocking"  (conductive  anaesthesia). 

Anaesthesia  by  direct  application  is  obtained  by 
painting  the  part  with  a  solution  of  the  anaesthetic 
or  the  application  of  a  tampon  dipped  into  such 
solution.  For  example,  a  tampon  dipped  into  the 
anaesthetic  and  inserted  into  the  nares  will  cause 
anaesthesia  in  the  anterior  part  of  the  upper  jaw. 

Infiltration  anaesthesia  is  produced  by  the  hypo- 
dermic injection  of  the  anaesthetic  into  the  field  of 
operation. 

Conductive  anaesthesia  is  obtained  by  injecting 
the  anaesthetic  into  or  about  a  nerve  trunk,  pro- 
ducing anaesthesia  in  the  whole  area  of  distribu- 
tion of  that  particular  nerve ;  prohibiting  afferent 
impulses  traveling  along  this  nerve  and  its 
branches,  and  thus  preventing  their  reaching  the 
brain. 

The  following  example  will  illustrate  both  meth- 
ods. Suppose  a  lower  six-year  molar  is  to  be  ex- 
tracted : 

Infiltration  anaesthesia  would  be  produced  by  in- 
jecting the  buccal  and  lingual  aspects  of  the  alveo- 
lar process,  which  would  cause  a  loss  of  sensation 
in  and  about  that  tooth. 

Conductive  anaesthesia  would  be  induced  by  in- 


Different  Types  131 

jecting  the  mandibular  nerve  at  the  inferior  dental 
foramen,  which  would  produce  anaesthesia  in  that 
half  of  the  mandible  up  to  the  median  line,  anaes- 
thetizing all  teeth  in  that  half  of  the  lower  jaw, 
the  anaesthesia  lasting  for  an  hour  or  longer. 


II 

Solution  for  Local  Anaesthesia 

In  view  of  the  fact  that  local  anaesthesia  is  pro- 
duced by  hypodermic  or  hypomucous  injection  of 
the  anaesthetic  agent  in  solution,  and  this  solution 
is  brought  in  direct  or  indirect  contact  with  nerve 
and  other  tissues,  it  is  of  great  importance  that 
the  agent,  as  well  as  its  solvent  medium,  be  tol- 
erated by  the  tissues  without  injury  to  the  cellular 
elements. 

What  are  the  requisites  demanded  of  a  solution 
employed  to  produce  local  anaesthesia  ? 

1.  It  must  be  non-irritating  to  the  tissues. 

2.  It  must  be  readily  absorbable. 

3.  It  should  be  as  devoid  of  toxic  effects  as  pos- 
sible. 

In  studying  the  effects  of  agents  employed  to 
produce  regional  anaesthesia  we  have  to  consider : 

1.  The  solution  used  as  a  solvent  for  the  anaes- 
thetic agent  and  its  effects  upon  the  tissues. 

2.  The  physiologic  effects  of  the  anaesthetic  upon 
the  sensory  nerves. 

3.  The  physiologic  effects  of  the  anaesthetic  upon 
the  organism  as  a  whole,  or,  in  other  words,  its 
degree  of  toxity. 

132 


Solutions  133 

The  Solvent  Medium 

If  sterile  water  is  injected  hypodermically,  a 
wheal  is  formed  followed  by  osmotic  action  be- 
tween the  injected  liquid  and  the  contents  of  the 
tissue  cells. 

The  tissue  cells  by  endosmosis  take  up  water, 
swell  up  and  at  the  same  time,  by  exosmosis,  they 
give  up  some  of  their  salt  elements.  Water  as 
H,0  alone  does  not  exist  in  the  body,  water  al- 
ways being  the  solvent  or  suspending  medium  of 
organic  or  inorganic  substances. 

The  swelling  of  the  tissues  produces  a  certain 
amount  of  anaesthesia,  due  to  pressure  upon  the 
terminal  nerves,  on  one  hand;  and  on  the  other, 
the  sensibility  of  the  part  is  also  reduced  by  the 
physical,  or  maybe  even  chemical,  changes  taking 
place  in  the  nerve  cells,  due  to  the  injection.  The 
resulting  anaesthesia  is  always  preceded  by  pain, 
is  of  short  duration,  very  unsatisfactory  and  at- 
tended by  disturbance,  or  rather  irritation,  of  the 
tissue  cells,  which  frequently  leads  to  necrosis. 

If  a  little  salt  (sodium  chloride)  is  added  to  the 
water,  and  this  solution  is  injected,  the  pain  is 
somewhat  less  and  will  decrease,  as  the  salt  con- 
tent of  the  solution  is  increased  until  isotonicity 
to  the  blood  is  reached. 

Then  there  is  absolutely  no  discomfort  felt  but 
no  anaesthesia.  If  the  salt  is  increased  beyond 
().!)  per  cent.,  pain  reappears,  anesthesia  follows 


134  Local  Anaesthesia 

and  the  tissue  cells  suffer.  These  phenomena  in- 
crease proportionately  as  more  salt  is  added.  It  is 
impossible  to  bear  the  pain  attending  an  injection 
of  a  saline  solution  containing  more  than  10  per 
cent,  sodium  chloride. 

The  foregoing  (experiments  made  by  Braun 
and  Heinze)  shows  that  saline  solutions  for  hypo- 
dermic injections  to  be  non-irritating  must  con- 
tain a  definite  amount  of  salt.  The  concentration 
of  this  solution  must  correspond  to  the  concentra- 
tion of  the  blood.  In  other  words,  it  must  be  iso- 
tonic. The  object  of  the  solution  is  simply  to  act 
as  a  diluent  and  carrier  for  the  anaesthetic.  The 
saline  solution  does  not  produce,  in  fact  should  not 
produce,  anaesthesia ;  the  pain  abolisher  is  the 
anaesthetic,  and  the  saline  solution  is  simply  the 
means  of  transporting  the  drug  into  the  nerve. 

A  solution  of  sodium  chloride  0.6  per  cent-0.9 
per  cent,  in  water  is  designated  as  physiologic  or 
normal  salt  solution. 

If  the  injected  solution  is  hypotonic  (less  con- 
centrated than  the  blood  plasma),  the  cellular  ele- 
ments will  take  up  water  from  the  solution  and 
swell  up;  in  the  case  of  red  blood  cells  actual 
hemolysis  may  result. 

If  the  injected  solution  is  hypertonic  (more  con- 
centrated than  the  blood  plasma),  the  tissue  and 
blood  cells  will  give  up  part  of  their  aqueous  con- 
tents and  shrink.    If  the  solution  is  isotonic  to  the 


Solutions  135 

blood,  then  an  even  absorption  of  the  injected 
liquid  takes  place.  Normal  salt  solution  is  such  an 
agent. 

Prof.  Guido  Fischer  of  late  advocates  the  use 
of  Ringer's  solution  in  lieu  of  normal  saline  solu- 
tion as  the  solvent  for  local  anaesthetics.  Ringer's 
solution  contains,  besides  sodium  chloride,  cal- 
cium and  potassium  chloride.  It  was  found  that 
the  tissues  take  up  the  mixed  chlorides  even  better 
than  sodium  chloride  alone,  as  they  make  a  more 
isotonic  solution  to  blood  plasma  than  normal  salt 
solution. 

The  importance  of  a  solvent  medium  isotonic  to 
the  blood,  containing  no  ingredients  which  will  in- 
terfere with  normal  absorption  or  irritate  the  tis- 
sue cells,  cannot  be  emphasized  sufficiently,  and 
any  operator  who  uses  proprietary  or  secret  nos- 
trums for  hypodermic  injections,  the  composition 
of  which  he  is  not  absolutely  acquainted  with,  can- 
not be  criticized  severely  enough. 

It  is  more  accurate,  cleaner,  and  therefore  safer, 
to  prepare  the  solutions  for  local  anaesthetics  in 
the  office  than  to  purchase  solutions  in  stock  bot- 
tles. A  very  convenient  method  is  the  purchasing 
of  anaesthetic  solutions  in  ampules ;  one  must  be 
certain,  however,  that  they  are  permanently 
sterile.  G.  Fischer  bought  some  ampules  in  open 
market  and  found  that  some  showed  the  presence 
of  cocci  after  a  few  months. 

If  the  ampules  are  sterile,  the  end  is  merely 


136  Local  Anesthesia 

broken  off,  the  needle  inserted  and  the  contents 
drawn  into  the  syringe ;  it  does  away  with  keeping 
of  stock  saline  or  Ringer's  solutions,  and  the  boil- 
ing of  the  tablet.  The  writer  is  still  preparing 
his  own  anaesthetic  solution,  as  described  herein. 

The  writer  would  hold  any  operator  directly  re- 
sponsible for  unpleasant  after-effects  from  hypo- 
dermic injections  if  the  operator  does  not  know 
the  exact  ingredients  of  a  solution  employed.  It 
is  the  writer's  opinion  that  carbolic  acid,  potas- 
sium iodide,  iodine,  baptisia,  hamamelis  and  the 
hundred  and  one  other  drugs  as  ingredients  in 
local  anaesthetics  placed  upon  the  market  have  ab- 
solutely no  place  in  such  preparations,  and  they 
can  only  exist  and  enjoy  a  sale  due  to  the  igno- 
rance of  the  profession  at  large. 

The  important  feature  about  a  local  anaesthetic 
is  not  the  anaesthesia  alone,  which  is  obtained  with 
many  preparations  on  the  market,  but  a  very  im- 
portant factor  is  that  the  tissues,  after  anaesthe- 
sia has  passed  off,  be  left  unharmed.  This  state 
can  only  be  obtained  by  a  non-irritating  isotonic 
solution. 

Postanaesthetic  pain,  oedema,  gangrene,  necro- 
sis, embolism,  ecchymosis  and  other  undesirable 
and  harmful  results  after  local  anaesthesia  are 
caused  by  lack  of  asepsis,  for  which  the  operator 
is  responsible,  or  the  injection  of  media  which 
cause  the  death  of  tissue  cells. 

The  action  of  the  anaesthetic  should  simply  be 


Solutions  137 

a  temporary  inhibition  of  impulse  transmission 
without  destroying  tissue  cells.  It,  therefore,  is 
apparent  that  the  proper  solvent  medium  for  pro- 
ducing local  anaesthesia  is  important  and,  in  the 
light  of  modern  science,  not  a  question  of  choice — 
only  normal  saline  or  Ringer's  solution  can  be 
considered. 

Preparation  of  the  Solvent  Medium 

Chemically  pure  sodium  chloride  tablets  for 
making  normal  salt  solution  can  be  purchased 
from  any  of  the  well-known  drug  houses.  These 
tablets,  in  well-corked  colored  bottles,  will  keep 
a  long  time.  One  tablet,  according  to  weight,  is 
dissolved  in  the  proper  amount  of  previously 
boiled  sterile  water  {this  does  not  mean  tap-water 
which  has  been  boiled,  but  distilled  water  which 
has  been  sterilized),  so  that  a  0.6  per  cent,  sodium 
chloride  solution  is  obtained.  If  a  tablet  weighs 
2  grm.  (30.9  grs.),  three  tablets  dissolved  in  one 
litre  will  give  the  proper  solution.  Ringer  solu- 
tion tablets  (Farbwerke,  Hoechst  Co.),  dissolved 
according  to  directions  (one  tablet  in  10  ccm.  of 
water),  will  give  Ringer's  solution. 

These  solutions  can  be  kept  in  alkali-free  stock 
bottles,  but  they  must  be  well  stoppered.  The 
author  uses  a  ground-glass  stoppered  bottle,  over 
which  a  ground-glass  cap  is  placed  (Fig.  84). 
Three  or  lour  ounces  (90-120  ccm.)  are  prepared, 
which  lasts  for  several  days.  The  least  cloudiness 
of  the  solution  makes  it  unfit  for  use. 


Ill 

The  AkMx\mentakium 

The  Syringe 

The  syringe  should  be  a  good  all-metal  and  glass 
syringe,  holding  40  min.,  or  one  having  a  tight- 
fitting,  interchangeable  asbestos  plunger.  A 
syringe  with  leather  washers  or  plungers  is  not 
fit  for  this  work,  as  the  leather  is  affected  by  boil- 
ing and  alcohol. 

The  author  uses  a  Freienstein  syringe  made  of 
glass  and  metal,  excepting  the  plunger,  which  is  a 
pad  of  asbestos.  All  parts  are  interchangeable 
(Fig.  83).  Prof.  Guido  Fischer  employs  an  in- 
strument of  the  same  make,  devised  by  himself, 
made  entirely  of  metal  and  glass,  with  a  revolving 
hand-rest. 

The  writer  finds  Fischer's  syringe  a  little 
too  heavy;  but  in  the  end  it  makes  little  dif- 
ference which  type  of  syringe  is  employed,  as  long 
as  it  is  capable  of  sterilization  and  none  of  its 
parts  injured  by  alcohol. 

The  syringes  are  kept  in  a  jar,  which  contains 
a  metal  stand  holding  several  syringes  (Fig.  84). 
The  jar  is  filled  with  a  mixture  of  70  per  cent,  alco- 
hol and  30  per  cent,  glycerine,  and  the  syringes  re- 

138 


Armamen  tarium 


139 


Fig.  83 
The   Instrument  Towards  the  Extreme  Left  Is  Prof.  Fischer's 
Syringe.    The  One  in  the  Center  Is  the  One  Mbst  Frequently  Used 
by  the  Author.    The  One  on  the  Right  is  Prof.  Williger's  Mandibu- 
lar Syringe;  This  Only  Holds  1  ccm. 


main  in  the  mixture  when  not  in  use.  When  they 
are  to  be  used  they  are  removed  from  the  alcohol 
mixture  and  washed  in  sterile  water,  and  sterile 
water  is  passed  in  and  out  of  the  barrel,  repeat- 
edly, so  as  to  remove  every  trace  of  glycerine  and 
alcohol  before  the  anaesthetic  is  drawn  into  the 
syrimj". 


140  Local  Anesthesia 

Needles 

The  author  uses  two  types  of  steel  needles :  for 
mandibular  injections,  the  No.  1  (0.90  mm.  in 
diameter),  40  mm.  long,  and  for  all  other  injec- 
tions the  No.  17  (0.47  mm.  in  diameter),  42  mm. 
long.  All  needles  fit  into  a  hub,  which  is  screwed 
upon  the  syringe  and  drawn  tight  with  a  wrench. 

The  needles  are  made  of  seamless  tube;  the 
mounting  consists  of  a  soft  metal  head  and  a  thin 
but  strong  hard  metal  casing.  The  soft  metal 
forms  an  absolutely  tight  joint  with  the  end  of  the 
syringe,  and  the  hard  metal  prevents  the  needle 
from  sticking  in  the  hub,  and  also  prevents  the 
soft  metal  from  becoming  distorted. 

These  needles  offer  decided  advantages  over  the 
old-fashioned  threaded  needle,  which  is  screwed 
directly  onto  the  syringe.  They  are  cleaner  and 
form  a  closer  joint  with  the  syringe,  so  there  is 
practically  no  leakage.  The  author  uses  the  steel 
needles  with  satisfactory  results.  The  Platinum- 
Tridium  needle  offers  the  advantage  that,  once 
mounted  upon  the  syringe,  it  need  not  be  removed, 
as  it  is  sterilized  by  burning  it  in  the  alcohol  flame. 
The  steel  needle  and  hub,  of  course,  are  removed 
after  being  used  once,  and  changed  for  a  new  one. 
Some  men  advocate  the  discarding  of  the  steel 
needle  after  using  it  once ;  the  author,  who  received 
part  of  his  training  in  Prof.  Williger's  Clinic, 
still  adheres  to  the  method  used  there.    Williger 


Armamentarium  141 

does  not  discard  his  needles  after  using  them,  but 
sterilizes'  them  and  employs  them  again.  How- 
ever, each  needle  is  carefully  inspected  before  be- 
ing sterilized  and  the  slightest  defect  condemns 
it  to  the  scrap-pail.  The  author  would  sound  a 
note  of  warning  to  exercise  great  care  in  the  use 
of  steel  needles :  to  carefully  inspect  them  daily 
before  sterilizing,  so  as  to  note  any  defect  and 
discard  them  at  once  if  a  flaw  is  discovered. 

A  rusty  needle  means  trouble,  and  a  broken 
needle  a  lot  of  anxiety,  for,  as  a  rule,  only  a 
surgeon  can  remove  it. 

If  a  needle  fractures  at  the  hub,  there  is  a  chance 
to  grasp  it  with  anatomical  forceps  and  withdraw 
it,  but  if  it  breaks  distal  to  the  hub  within  the  tis- 
sues, its  removal  can  only  be  done  by  a  surgeon. 

The  possibility  of  fracture  caused  a  good 
many  operators  to  use  Platinum-Iridium  needles. 
These,  however,  after  heating  repeatedly,  get 
quite  soft  and  make  the  palpation  of  the  bone  (in 
mandibular  injections)  rather  difficult. 

There  is  less  chance  for  needles  to  break  in  other 
injections  than  in  mandibular  anaesthesia. 

The  needles  are  washed  out  after  using,  the  wire 
is  drawn  through  them,  they  are  then  boiled  and 
then  placed  in  a  closed  vessel  containing  the  alco- 
hol and  glycerine  mixture,  or  in  pure  lysol.  If  they 
are  kept  in  lysol,  they  have  to  be  washed  thor- 
oughly in  sterile  water,  to  remove  all  traces  of 


Armamentarium  143 

lysol,  before  attaching  to  the  syringe.  If  they  are 
kept  in  the  glycerine-alcohol  mixture,  they  are,  of 
course,  also  washed  in  sterile  water  to  remove 
every  vestige  of  alcohol  and  glycerine.  The  chucks 
or  hubs  are  treated  just  the  same  as  the  needles. 
Fig.  84  shows  the  author's  arrangement  of  his 
local  anaesthesia  armamentarium. 

Nos.  1.  and  2.  are  glass  jars,  containing  a  metal 
stand  holding  the  syringes.  (Jar  2.  also  holds  a 
novocain  crucible.)  Each  jar  is  partially  filled 
with  alcohol-glycerine. 
No.  3.  is  a  jar  for  needles  containing  lysol. 
Nos.  5.  and  6.  are  glass-stoppered,  glass-capped 
bottles  containing  Ringer's  solution. 

No.  7.  is  another  bottle  for  Ringer's  solution,  de- 
vised by  Dr.  Riethmuller,  of  Philadelphia. 

No.  8.  is  a  minim  graduate ;  when  not  in  use,  it 
is  stopped  with  absorbent  cotton. 

No.  9.  are  three  medicine  glasses,  each  of  differ- 
ent color,  to  hold  novocain  powder  or  other  drugs. 
No.    10.    is    a    porcelain    crucible    for    boiling 
Ringer's    solution    and   preparing  novocain   for 
injection. 

Nos.  11.,  12.  and  13.  are  enamel  dishes  holding 
sterile  water.  No.  11.  is  to  wash  off  the  syringe 
when  it  is  removed  from  the  jar;  No.  12.  is  to 
wash  off  needles,  and  No.  13.  is  to  wash  out  the 
syringe. 


144  Local  Anesthesia 

No.  14.,  alcohol  lamp  for  boiling  solutions  and 
to  burn  off  platinum-iridium  needle. 

No.  4.  are  glass  slabs  to  cover  the  porcelain  cru- 
cible (10.)  and  the  medicine  blocks  (9.),  so  that  no 
dust  contaminates  their  contents. 

The  glass  table  is  used  for  nothing  else  but  the 
preparation  of  anaesthetic  solutions. 

Steps  of  Injection 

1.  Boil  Ringer's  solution  in  crucible. 

2.  Drop  novocain-suprarenin  tablets  in  crucible 
and  bring  to  boiling  point  to  dissolve  tablets ;  place 
glass  cover  on  crucible. 

3.  Remove  syringe  from  jar,  wash  outside  in 
sterile  water  and  dry  in  sterile  towel;  do  not  re- 
move cap. 

4.  Remove  needle  and  hub  from  jar  with  pliers, 
and  wash  with  sterile  water  in  special  dish. 

5.  Remove  cap  from  syringe,  attach  needle  and 
hub  with  pliers  and  wrench. 

6.  Pass  sterile  water  in  and  out  of  syringe,  a 
third  special  dish. 

7.  Fill  syringe  with  anaesthetic. 

8.  Iodize  mucous  membrane. 

9.  Inject  anaesthetic;  wipe  needle  with  sterile 
cotton. 

10.  Remove  needle  and  hub,  wash  in  sterile 
water,  replace  wire  into  needle,  then  sterilize  by 
boiling. 


Technique  145 

11.  "Wash  syringe  by  passing  fresh  sterile  water 
in  and  out,  attach  cap,  wash  outside  of  syringe, 
dry. 

12.  Eeplace  into  jar. 

//  Platimim-Iridium  Needle  Is  Used 

1.  Boil  Ringer's  solution  in  crucible. 

2.  Drop  novocain-suprarenin  tablets  into  cruci- 
ble and  bring  to  boiling  point  to  dissolve  tablets ; 
place  glass  cover  on  crucible. 

3.  Remove  syringe  from  jar,  wash  outside  in 
sterile  water  and  dry  in  sterile  towel. 

4.  Wash  out  syringes  in  sterile  water. 

5.  Sterilize  needle  in  alcohol  flame. 

6.  Pill  syringe  with  anaesthetic. 

7.  Burn  off  needle. 

8.  Iodize  mucous  membrane. 

9.  Inject  anaesthetic,  wipe  needle  with  sterile 
cotton. 

10.  Burn  off  needle. 

11.  Wash  out  syringe,  dry  outside. 

12.  Replace  syringe  and  needle  into  jar. 


IV 

Cocaine 

Local  anaesthesia  only  became  an  established  fact 
after  the  recognition  of  cocaine  as  an  anaesthetic 
agent.  Prior  to  this  time  compression  of  nerve 
trunks,  the  application  of  cold  by  freezing  mix- 
tures and  the  spraying  of  ether  and  other  volatile 
substances  were  practised,  but  all  this  with  indif- 
ferent and  unsatisfactory  results. 

History 

Pizarro,  when  invading  Peru  in  1532,  discovered 
that  the  inhabitants  of  that  country  cultivated  the 
Coca  plant  (Erythroxylon  Coca)  and  chewed  the 
leaves  to  appease  hunger  and  to  overcome  fatigue. 

Messengers  running  long  distances  carried  a 
supply  of  coca  leaves  for  artificial  stimulation  and 
cutting  down  rations  and  sleep.  It  was  also  known 
that  the  excessive  use  of  the  plant  proved  very 
harmful.  The  Spanish  government  prohibited  the 
general  cultivation  of  the  coca  plant  for  some 
time;  later,  however,  permitted  its  growing,  but 
levied  a  tax  upon  its  production.  By  this  taxation 
the  State  of  Bolivia  during  1850,  according  to 
Wendell,  netted  a  revenue  of  three  million  dollars. 

The  first  to  bring  a  larger  quantity  of  coca 
leaves  to  Europe  was  Scherzer.    Part  of  this  sup- 

146 


Cocaine  147 

ply  was  given  to  "Wohler  in  Gottingen,  Germany, 
whose  scholars  Niemann  and  Lossen  were  the  first 
to  produce  the  alkaloid  cocaine.  Later  cocaine 
was  produced  synthetically  by  Merck,  Einhorn, 
Liebermann  and  others. 

Cocaine,  Ci7H2N04,  is  an  alkaloid  obtained  from 
the  leaves  of  Erythroxelon  Coca ;  it  occurs  in  color- 
less, quadrilateral,  or  hexagonal  crystals,  sparing- 
ly soluble  in  water  (1:  700),  very  soluble  in  alco- 
hol, ether  and  chloroform ;  it  has  a  bitter  taste,  and 
when  placed  upon  the  tongue  causes  a  local  sensa- 
tion of  numbness.  With  acids  it  forms  salts.  The 
one  chiefly  used  is  cocaine  hydrochlorate, 
C17H24No4H. 

The  history  of  cocaine  as  an  anaesthetic  dates 
back  as  far  as  1855,  when  Garmecke  noted  that  a 
certain  amount  of  lingual  anaesthesia  is  induced  by 
chewing  the  coca  leaves.  In  1857  Percy  found  a 
more  marked  anaesthesia  by  placing  Erythroxylon 
(another  product  of  the  plant)  upon  the  tongue, 
and  in  1860  Niemann  found  the  same  action,  only 
more  marked,  produced  by  cocaine. 

Denarle,  Schrofr"  (1862),  Morens  y  Maiz  (1868), 
Von  Anrep  (1879),  conducted  experiments  with 
the  newly  found  substance,  and  the  last  named  was 
the  first  to  inject  cocaine  subcutaneously  into  his 
arm,  and  obtained  local  anaesthesia  by  the  hypo- 
dermic method. 

Borderau  and  Coupard  (1880)  found  that  the 


148  Local  Anesthesia 

instillation  of  a  cocaine  solution  into  the  eyes  of 
animals  abolished  ocnlar  reflexes,  and  Pauvel, 
Saglia  and  others  employed  cocaine  in  the  treat- 
ment of  painful  affections  of  the  larynx  and 
pharynx. 

However,  cocaine  was  not  universally  acknowl- 
edged and  accepted  as  an  anaesthetic  agent  until 
Karl  Roller,  of  Vienna  (now  of  New  York),  in 
1884,  before  the  Ophthalmological  Congress  at 
Heidelberg,  demonstrated  that  the  instillation  of  a 
2  per  cent,  solution  of  cocaine  into  the  eye  per- 
mitted the  performance  of  ophthalmological  oper- 
ations without  pain. 

Physicians  all  over  the  world  began  to  use  it, 
and  scientists  took  up  the  study  of  this  new  drug. 
The  report  of  Koller  was  soon  corroborated  by 
Agnew,  Moore,  Minor,  Knapp,  Grafe  and  others, 
and  the  cocainization  of  the  eye  and  mucous  mem- 
brane became  universal.  Cocaine  soon  established 
itself  in  laryngology  and  rhinology,  and  was  also 
used  in  genito-urinary  practice.  Soon  surgery,  as 
well  as  dentistry,  made  use  of  the  wonderful  prop- 
erties of  this  drug.  In  1885  Corning  reported  that 
if  the  circulation  be  cut  off  in  the  part  to  be  anaes- 
thetized, the  action  of  the  drug  became  intensified, 
and  anaesthesia  is  obtained  with  much  weaker  so- 
lutions, thus  reducing  the  toxic  effects.  To  pro- 
duce anaemia  in  the  part,  he  employed  Esmarch 
bandages.    This  discovery  was  the  forerunner  of 


Cocaine  149 

our  present  dry  method  of  producing  local  anaes- 
thesia coupled  with  anaemia  (anaesthetic  plus 
adrenalin).  Corning  and  Goldscheider  demon- 
strated that  the  conductivity  of  impulses  along  the 
nerve  is  inhibited  by  the  injection  of  cocaine,  and 
this  in  turn  is  the  forerunner  of  conductive 
anaesthesia. 

How  rapidly  these  findings  were  utilized  was 
demonstrated  by  Halstedt,  of  Philadelphia,  who 
in  1885  injected  the  inferior  dental  nerve  for  tooth 
extraction.  Cocaine  was  taken  up  all  over  the 
globe  by  all  who  practised  the  healing  art.  It  was 
used  in  2  to  20  per  cent,  solutions,  and  no  sooner 
was  it  employed  here,  a  new  use  was  found  for  it 
there,  but  soon  severe  cases  of  poisonings  and 
fatalities  beg'an  to  be  reported.  The  new  gift  of- 
fered to  humanity  proved  a  double-edged  sword. 
By  virtue  of  its  wonderful  anaesthetic  properties, 
undreamed-of  advances  were  made  in  all  special- 
ties in  medicine,  but  its  use  frequently  proved 
dangerous,  and  the  number  of  cocaine  fatalities  is 
much  greater  than  those  reported. 

Physiologic  Action  of  Cocaine 

The  symptoms  of  cocaine  poisoning  vary  in  dif- 
ferent individuals.  In  most  cases  small  quantities 
produce  some  excitement,  pleasurable  and  dis- 
agreeable. The  patient  is  generally  more  garru- 
lous than  in  ordinary  life,  often  somewhat  anxious 


150  Local  Anaesthesia 

and  confused.  Very  small  doses  produce  a  calm, 
languorous  state,  somewhat  resembling  that  fol- 
lowed by  taking  small  quantities  of  morphine,  but 
differing  from  it  in  there  being  less  tendency  to 
sleep.  The  pulse  is  accelerated,  the  respiration 
quick  and  deep,  the  pupil  generally  dilated,  and 
headache  and  dryness  of  the  throat  are  frequently 
complained  of.  The  reflexes  may  be  a  little  exag- 
gerated and  tremors  or  slight  convulsive  move- 
ments may  occur.  Later  powerful  tonic  or  clonic 
convulsions  supervene,  the  heart  becomes  ex- 
tremely accelerated,  the  breathing  becomes  rapid 
and  dyspnceic  and  may  finally  be  arrested  during 
a  convulsion.  In  other  cases  the  convulsive 
seizures  are  almost  entirely  absent,  and  fainting 
and  collapse  occur.  The  skin  is  cyanotic  and  cold, 
the  heart  slow  and  weak;  the  respiration  is  very 
much  depressed,  and  death  follows  from  its  grad- 
ual cessation.  Vomiting  is  occasionally  seen  at 
an  early  stage,  but  is  by  no  means  common. 

The  general  action  of  cocaine  seems  to  indicate 
a  stimulation  of  the  central  nervous  system.  Thus 
the  talkativeness  so  often  produced  by  the  drug 
indicates  an  increased  activity  of  the  cerebrum, 
and  the  increased  movement  in  lower  animals  dis- 
tinctly points  to  an  affection  of  this  part  of  the 
brain,  for  the  movements  are  perfectly  coordi- 
nated, and  in  the  early  stages  resemble  exactly 
those  performed  by  the  normal  animal  in  a  state 


Cocaine  151 

of  excitement.  Further  evidence  of  the  action  of 
cocaine  on  the  cerebrum  is  shown  by  its  effects 
on  muscular  work. 

The  action  of  cocaine  on  the  central  nervous  sys- 
tem is  primarily  a  descending  stimulation,  the  cere- 
brum being  affected  first,  then  the  hind  brain  and 
medulla  oblongato,  and  last  of  all  the  spinal  cord. 
Perhaps  it  might  be  better  expressed  by  saying 
that  after  small  quantities  the  chief  symptoms 
arise  from  the  cerebrum,  but  as  the  dose  is  in- 
creased those  from  the  lower  part  of  the  central 
axis  become  more  prominent.  After  stimulation 
there  succeeds  depression,  which  follow  the  stimu- 
lation downward,  affecting  first  the  cerebrum  and 
then  the  lower  divisions.  The  two  stages  are  not 
definitely  divided,  however,  one  part  of  the  cere- 
brum showing  distinct  depression,  while  another 
is  still  in  ,a  state  of  excessive  activity.  In  some 
cases,  especially  in  man,  the  stage  of  excitement 
may  be  very  short  or  apparently  absent,  and  the 
whole  course  of  symptoms  then  point  to  medullary 
depression. 

In  some  instances  there  obtain  erotic  illusions 
and  incoordinate  hallucinations;  the  operator 
should  be  mindful  of  these  effects,  as  the  effects  of 
a  local  anaesthesia,  just  the  same  as  narcosis,  may 
place  him  in  an  embarrassing  position.  Prof. 
Fischer  quotes  Ritter,  who  reports  the  following 
case: 


152  Local  Anesthesia 

According  to  Hentze,  a  young  lady  presented  at 
a  clinic  and  had  a  tooth  removed  under  local  anaes- 
thesia. She  showed  symptoms  of  cocaine  intoxi- 
cation and  hysteria ;  however,  recovered  very  soon 
and  returned  to  her  home.  Soon  thereafter  one  of 
the  assistants  received  letters  from  her  of  amorous 
character,  though  she  even  did  not  know  the  as- 
sistant's name.  The  assistant  paid  no  attention 
to  these  notes,  and  three  days  later  the  young 
woman  committed  suicide,  after  notifying  the  as- 
sistant of  her  intention.  It  was  determined  the 
young  woman  was  of  unreproachable  character 
and  engaged  to  be  married.  Her  actions,  no  doubt, 
were  caused  by  the  reaction  of  the  cocaine  produc- 
ing erotic  conditions  of  the  mind. 

The  author  himself  observed  several  cases  of 
marked  sexual  excitement  followed  by  orgasm, 
while  the  patient  was  lying  in  the  chair,  showing 
symptoms  of  cocaine  intoxication,  resulting  upon 
local  anaesthesia  induced  for  the  extraction  of 
teeth. 

Respiration  after  cocaine  is  much  accelerated, 
owing  to  central  stimulation.  At  first  the  depth 
is  not  changed,  but  as  the  acceleration  progresses 
the  air  inspired  with  each  breath  gradually  be- 
comes less.  During  convulsions  the  respiration  is 
irregular  or  ceases,  but  it  recovers  again  in  the  in- 
tervals, until  after  a  very  violent  paroxysm  it  fails 
to  be  reinstated.    In  other  cases  the  breathing  be- 


Cocaine  153 

comes  slower  and  weaker  after  a  time,  and  eventu- 
ally stops  from  paralysis  of  the  center. 

The  circulation  is  altered  by  cocaine,  owing  to 
its  action  on  the  heart  and  on  the  vessels.  The 
heart  is  much  accelerated  in  mammals,  while  in  the 
amphibians  this  is  less  often  observed.  The  quick- 
ening has  been  ascribed  to  paralysis  of  the  inhib- 
itory terminations,  but  this  seems  not  to  be  the 
case,  for  stimulation  of  the  vagus  slows  the  heart 
even  late  in  the  poisoning.  The  heart  is  ac- 
celerated, then  either  by  direct  action  of  the  muscle 
or  by  stimulation  of  the  accelerator  mechanism. 
It  is  often  slow  before  death,  but  apparently  not 
invariably,  and  this  is  probably  due  to  direct  ac- 
tion on  the  muscle. 

The  vessels  are  much  contracted  in  the  earlier 
stages  of  poisoning,  and  this,  together  with  the 
increased  rate  of  the  heart,  leads  to  a  very  con- 
siderable rise  in  the  blood  pressure.  The  constric- 
tion of  the  vessels  seems  partly  due  to  stimulation 
of  the  vaso  constrictor  center,  for  section  of  the 
splanchnic  nerves  leads  to  direct  fall  in  the 
arterial  tension.  Cocaine  seems  to  act  directly 
upon  the  walls  of  the  blood  vessels,  as  its  local  ap- 
plication is  followed  by  constriction  of  the  vessels 
and  blanching  of  the  mucous  membrane. 

The  effects  on  the  peripheral  nerves  and  muscles 
are  still  disputed. 

The  urine  is  sometimes  said  to  be  increased  by 


154  Local  Anesthesia 

cocaine,  while  in  other  instances  its  injection  has 
been  followed  by  anuria  lasting  several  hours. 
The  other  secretions  seem  rather  reduced. 

The  temperature  rises  in  cases  of  poisonings  as 
much  as  3-5  C. 

The  elimination  of  cocaine  from  the  organism 
is  still  a  muted  question.  In  dogs  a  portion  is  ex- 
creted by  the  kidneys,  the  greatest  portion,  95  per 
cent.,  being  destroyed  in  the  tissues.  In  the  rabbit 
it  is  completely  oxidized.  In  man  the  final  state 
of  cocaine  is  not  definitely  established. 

Local  Effects  of  Cocaine 

Cocaine  applied  locally  in  most  parts  of  the 
body  produces  a  loss  of  sensation  by  its  paralyz- 
ing the  terminations  of  some  of  the  sensory  nerves, 
particularly  those  conveying  impressions  of  pain 
and  touch.  It  is  often  stated  that  the  end  organs 
of  the  nerves  concerning  which  the  feeling  of  heat 
and  cold  are  also  disorganized,  but  the  researches 
of  Kiesow  show  that  this  is  incorrect,  and  that 
heat  and  cold  are  recognized  as  readily  as  in  the 
unaffected  parts  of  the  body.  Cocaine  applied  to 
the  tongue  removes  the  taste  of  bitter  substances, 
while  sweet  and  acid  fluids  lose  their  taste  only 
partially,  and  salt  is  recognized  as  easily  as 
usually. 

A  solution  applied  to  the  nasal  mucous  mem- 
brane paralyzes  the  sense  of  smell  entirely. 


Cocaine  155 

Anaesthesia  or  insensibility  to  pain  and  touch 
may  be  induced  in  any  of  the  mucous  membranes 
that  can  be  reached  by  cocaine  in  sufficient  concen- 
tration— pharynx,  larynx,  oesophagus,  stomach, 
nose,  eye,  urethra,  bladder,  vagina  and  rectum. 

Applied  to  the  unbroken  skin,  its  effects  are  less 
marked,  as  it  penetrates  but  slowly  through  the 
horny  epidermis;  but  when  the  epidermis  is  re- 
moved by  abrasions  or  by  skin  disease,  the  cuta- 
neous organs  of  sensation  are  acted  on  in  the  same 
way  as  those  of  the  mucous  membrane. 

The  deeper  sensory  terminations  can  also  be 
acted  on  by  hypodermic  injections,  which  causes 
a  feeling  of  numbness  and  the  relief  of  pain  in  the 
part.  Hypodermic  injection  reaches  not  only  the 
nerve  terminations  of  the  subcutaneous  tissues, 
but  also  the  finer  nerve  bundles,  and  these,  too, 
are  rendered  insensible  as  far  as  the  solution  ex- 
tends to  them. 

The  part  may,  therefore,  be  cut  into  or  be  sub- 
jected to  other  surgical  treatment  without  pain, 
as  long  as  the  knife  does  not  pass  beyond  the  area 
to  which  the  drug  has  penetrated,  and  numbers  of 
grave  surgical  operations  have  been  performed 
under  local  anaesthesia  produced  by  cocaine.  In- 
jected into  the  neighborhood  of  a  nerve  trunk,  co- 
caine penetrates  into  the  fibres  and  induces  anaes- 
thesia of  the  organs  supplied  by  that  nerve,  and 
injected  into  the  spinal  canal  causes  anaesthesia 


156  Local  Anaesthesia 

over  large  areas  of  the  body,  sometimes  over  al- 
most the  whole  body.  This  is  probably  due  to  its 
acting  on  the  posterior  roots  of  the  cord.  It  must 
be  noted  that  the  anaesthesia  is  only  produced  by 
the  local  applications  of  the  drug.  The  internal 
administration  only  leads  to  a  partial  loss  of  sen- 
sation in  the  throat  and  stomach,  and  no  anaesthe- 
sia is  induced  by  its  action  after  it  reaches  the 
blood  vessels.  The  reason  for  this  evidently  is 
that,  in  order  to  paralyze  the  sensory  fibres  and 
terminations,  a  considerable  amount  of  the  drug 
is  required,  but  much  less  is  necessary  to  paralyze 
the  central  nervous  system  when  cocaine  is  ap- 
plied to  a  mucous  membrane  surface ;  it  produces, 
besides  loss  of  sensation,  a  feeling  of  constriction 
and  a  distinct  pallor  and  contraction  of  the  ves- 
sels, which  points  to  a  local  action  on  the  vessel 
walls;  The  anaesthesia  produced  by  cocaine  is 
comparatively  short,  but  varies  with  the  strength 
of  the  solution  applied  and  with  the  vascularity  of 
the  part;  as  soon  as  the  cocaine  is  absorbed,  the 
local  action  disappears  and  sensation  returns. 

Cocaine  can  be  looked  upon  as  a  general  proto- 
plasmic poison;  muscles,  nerves  and  nerve  ends 
cease  to  contract  or  to  conduct  stimuli  when  ex- 
posed to  even  very  dilute  solutions  of  cocaine ;  the 
ciliated  epithelial  cells,  leucocytes  and  sperma- 
tozoa become  motionless ;  the  cortical  nerve  cells 
lose  their  excitability,  and  many  of  the  inverte- 


Novocaix  157 

brates  are  killed  by  even  short  exposure  to  co- 
caine. The  movements  of  protoplasm  in  plants 
are  also  retarded  or  entirely  suppressed,  and  pu- 
trefaction is  delayed  considerably.  In  some  cases, 
notably  in  the  higher  invertebrates,  the  final  de- 
pression is  preceded  by  a  stage  of  increased  move- 
ment. In  other  instances,  however,  cocaine  in- 
duces only  depression  and  paralysis. 

From  the  above  we  note  that,  though  cocaine 
has  proven  of  inestimable  value,  at  the  same  time 
it  is  a  powerful  poison,  and  chemists  and  investi- 
gators all  over  the  world  have  been  trying  to  pro- 
duce agents  which  possess  the  anaesthetic  proper- 
ties of  cocaine  but  are  devoid  of  its  toxic  qualities. 
The  substitutes  offered  for  cocaine  as  anaesthetic 
agents  are  many;  however,  all  had  their  short- 
comings :  either  their  toxity  was  practically  equal 
to  that  of  cocaine,  or  if  they  were  less  poisonous, 
the  anaesthesia  produced  by  these  agents  was  not 
satisfactory;  certainly  it  did  not  prove  equal  to 
that  of  the  coca  leaf  alkaloid. 

Novocain 

After  many  substitutes  for  cocaine  were 
brought  out  and  found  wanting,  Prof.  Einhorn,  of 
Munich,  in  1905  produced  hydro-chlorid  of 
p-amino-benzoyldiethylamincethanol,  which  re- 
ceived the  trade  name  "Novocain." 

Bibliography:  dishing,  Pharmacology  and  Therapeutics, 
liraun,  Die  Lokalanaesthesic.     Hare,  Practical  Therapeutics. 


158  Local  Anaesthesia 

Dr.  J.  Biberfeld  experimented  with  the  new 
drug  at  the  Pharmacological  Institute  of  the  Uni- 
versity of  Breslau,  which  experiments  gave  the 
following  data : 

Novocain  possesses  the  same  action  upon  sen- 
sory nerves  as  cocaine;  a  0.25  per  cent,  solution 
suffices  to  completely  anaesthetize  even  heavy  nerve 
trunks,  such  as  the  sciatic  nerve,  in  about  ten  min- 
utes. Applied  locally  it  causes  no  irritation,  even 
if  used  in  strong  solutions=  The  author  applies 
pure  novocain  powder  to  the  oral  mucous  mem- 
brane before  making  a  mandibular  injection,  and 
has  not  seen  any  ill  results  after  using  it  in  about 
five  hundred  mandibular  injections. 

There  appears  practically  no  ill  effect  upon  the 
system  after  its  absorption  in  doses  which  would 
be  dangerous  if  cocaine  were  used.  Neither  the 
circulation,  respiration  or  cardiac  activity  seem 
to  suffer.  Two  to  three  grains  (0.15-0.2  gr.)  of 
novocain  injected  subcutaneously  into  a  rabbit 
hardly  showed  a  change  in  the  blood  pressure  or 
the  respiratory  curve.  Novocain  does  not  produce 
mydriasis,  does  not  change  the  introoccular  pres- 
sure, and  does  not  affect  peripheral  vessels,  as 
cocaine  does. 

The  toxicity  is  very  low  compared  to  cocaine, 
and  was  determined  by  comparing  the  lethal  dose 
of  novocain  with  that  of  cocaine,  and  stovain  in 
animal  experiments. 


Novocain  159 

Lethal  dose  per  kilogram  of  bodyweigiit ;  drug- 
administered  subcutaneously : 

Cocaine  Stovain  Novocain 

Rabbit. 0.05-0.1    g.     0.15-0.17  g.     0.35-0.4  g. 
Dog  . .  .0.05-0.07  g.     0.15  g.  0.25  (not  lethal) 

Similar  results  were  obtained  experimenting 
with  frogs,  rats  and  cats,  using  the  drug  not  only 
subcutaneously,  but  also  intravenously.  Intro- 
ducing novocain  into  the  spinal  canal  also  demon- 
strated it  to  be  less  toxic  than  any  local  anaesthe- 
tic ever  produced. 

The  results  of  laboratory  experiments  show 
novocain  to  be  about  seven  times  less  toxic  than 
cocaine.  The  writer,  however,  is  inclined  to  place 
the  toxicity  even  lower  than  that,  and  considers 
it  about  ten  times  less  toxic  than  the  coca  product. 
The  writer  in  operating  for  a  cyst  of  the  upper 
jaw  once  used  9  ccm.  of  a  2  per  cent,  solution  of 
novocain,  thus  giving  0.2  g.  (3  grains)  without 
causing  alarming  symptoms. 

European  literature  abounds  with  favorable  re- 
ports on  the  use  of  novocain,  and  many  pages 
could  be  covered  with  the  enthusiastic  reports  by 
clinicians  of  all  medical  specialties.  It  is  being 
used  more  and  more  in  this  country,  and  Prinz,  of 
St.  Louis;  Blum,  of  New  York;  Riethmuller,  of 
Philadelphia;  Thoma,  of  Boston;  Cunningham, 
Schamberg,  Vaughn  and  others  are  advocating  its 
use  warmly.    "Einhorn  really  seems  to  have  dis- 


160  Local  Anesthesia 

covered  the  local  anaesthetic. ' '  In  spite  of  all,  the 
writer  would  warn  against  the  thoughtless  indis- 
criminate use  of  the  drug,  but  impress  the  reader 
that,  though  we  have  an  agent  that  is  a  great  deal 
less  toxic  than  cocaine,  we  still  have  to  study  our 
patients  and  use  judgment,  and  never  forget  the 
meaning  of  the  word  asepsis. 

Novocain  is  manufactured  in  three  forms : 

1.  Basic  novocain. 

2.  Novocain  nitrate. 

3.  Novocain  hydrochlorate. 

The  basic  form  is  mainly  used  in  otology,  rhinol- 
ogy  and  laryngology  in  10  per  cent,  solutions  in 
oil  for  applications,  instillations  and  inhalation. 

The  nitrate  is  particularly  of  value  in  urological 
practice,  as  the  nitrate  of  novocain  can  be  com- 
bined with  silver  salts,  which  is  not  possible  with 
the  chlorate,  the  latter  decomposing,  and  thus  los- 
ing its  properties. 

Adrenalin 
The  findings  of  Corning  (1885),  that  cocaine  in- 
jected into  an  anaemic  area  will  produce  anaesthe- 
sia in  weaker  solutions  and  lessen  the  toxic  effects 
due  to  a  smaller  amount  being  absorbed  into  the 
general  circulation,  became  of  practical  use  when, 
in  1901,  Takamine  and  Aldrich,  independent  of 
each  other,  produced  the  extract  of  the  suprarenal 
capsules  known  as  adrenalin. 


Adkenalin  161 

The  most  characteristic  action  of  adrenalin  is  a 
temporary  raising  of  the  blood  pressure,  even  if 
administered  in  minute  quantities.  According  to 
Moore  and  Purrington,  given  to  dogs  in 
0.000000245-0.000024  gm.  for  each  kilogram  of 
bodyweight,  its  action  is  discernible. 

The  reason  for  this  reaction  is  due  to  direct  car- 
diac stimulation,  and  also  to  the  contraction  of 
arterioles  and  capillaries. 

The  action  of  novocain  is  enhanced  by  adding  a 
small  quantity  of  adrenalin  or  suprarenin  synth. 
The  "E"  novocain  suprarenin  tablets  made  by  the 
Hochst  Farbwerke  Co.  contain  novocain  0.02  gram 
and  suprarenin  0.00005  gram,  and  are  the  most 
convenient  for  dental  practice. 

Where  large  quantities  of  novocain  are  used  it 
is  probably  better  to  make  up  a  iy2  or  2  per  cent, 
solution  of  novocain  and  then  add  1  drop  of  supra- 
renin for  each  cem.  of  novocain  solution. 

Any  systemic  symptoms  which  may  appear  after 
the  hypodermic  injection  of  novocain,  suprarenin 
namely,  the  blanching  of  the  patient,  perspiration 
and  slight  nausea,  are  due  to  suprarenin,  and  not 
to  the  novocain.  In  old  people  with  hardened  ves- 
sels and  in  arteriosclerosis,  as  well  as  wherever 
there  is  an  abnormal  high  blood  pressure,  it  is  ad- 
visable to  reduce  the  amount  of  suprarenin. 


V 

Infiltration  Anaesthesia 

Infiltration  anaesthesia  is  the  regional  loss  of 
sensation  produced  by  the  action  of  certain  agents 
upon  sensory  nerve  endings  introduced  by  subcu- 
taneous or  submucous  injection. 

How  these  agents  act  upon  the  nerve  tissue  di- 
rectly has  not  been  established  yet.  We  only  know 
the  result  of  such  action,  namely,  a  disturbed 
physiologic  function,  which  in  sensory  nerve  tissue 
is  exhibited  by  loss  of  sensation. 

The  author  believes  that  when  an  agent  like  co- 
caine, or  a  similarly  acting  drug,  is  brought  in 
contact  with  nerve  tissue,  there  occurs  a  precipi- 
tation or  coagulation  of  some  of  the  cell  contents 
(albumins),  which  altered  biologic  state  produces 
the  loss  of  function ;  after  this  precipitate  is  elimi- 
nated by  absorption  or  is  redissolved  within  the 
cell  body,  the  normal  function  is  reestablished 
without  apparent  injury  to  the  nerve  tissue,  and 
sensation  returns.  This  will  very  likely  account 
for  the  transient  character  of  the  drug  effect. 

In  employing  local  anaesthesia  it  is  not  only  es- 
sential to  be  acquainted  with  the  local  and  physio- 
logic action  of  the  drugs  used,  but  a  thorough 
knowledge  of    the    anatomical    and    histological 

162 


Infiltration 


163 


structure  of  the  parts  to  be  anaesthetized  is  re- 
quired. 

The  jaws  primarily  present  two  types  of  osseous 
structure:  first,  spongy  portions,  rich  in  canals 
and  spaces;  and,  second,  solid  portions,  very  poor 
in  perforations. 

In  view  of  the  fact  that  local  anaesthesia  depends 
upon  the  absorption  of  the  anaesthetic,  it  is  ap- 
parent that  those  parts  which  are  cancellous  in 


Fro.  85 
Showing  Porous  Character  of  Upper  Jaw  and 
Structure  in  Anti-riot   Portion  <>f  Mandible.     I.  infraorbital  Fora- 
l.   0.  I.    Externa]  Oblique  Line.    M.  Mental  Foramen. 


164  Local  Anesthesia 

structure  will  be  anaesthetized  more  satisfactorily 
than  the  solid  areas. 

The  upper  jaw  is  more  porous  in  structure  than 
the  mandible.  The  lower  maxilla  being  porous 
only  in  the  anterior  portion,  between  the  canine 
teeth,  infiltration  anaesthesia  will  prove  more  ef- 
fective here  than  in  the  bicuspid  and  molar  re- 
gions, where  the  bone  is  denser  in  character 
(Fig.  85). 

Another  point  to  bear  in  mind  is  the  fact  that 
the  maxillary  bones  are  more  porous  in  early  life, 
and  with  advancing  years  grow  more  compact  and 
denser ;  thus  it  will  be  easier  to  induce  anaesthesia 
with  less  of  the  drug  in  children  than  in  adults. 

Local  or  infiltration  anaesthesia  can  be  employed 
upon  single  or  groups  of  teeth  in  the  anterior  part 
of  the  mandible  and  in  the  upper  jaw,  provided 
there  is  no  infection  present. 

The  Technique  of  Infiltration  Anaesthesia 

Successful  local  anaesthesia  depends  upon  three 
factors :  local  asepsis,  the  use  of  the  proper  solu- 
tion, and  correct  technique.  The  second  factor 
has  been  discussed  elsewhere. 

Local  asepsis  is  obtained  by  applying  tr.  iodine 
to  the  part  to  be  injected.  This  is  best  done  with 
an  applicator,  made  by  tightly  winding  some  ab- 
sorbent cotton  around  one   end  of   a  toothpick. 


In  filtration  165 

This  method  is  simple,  inexpensive  and  clean,  as 
the  applicator  is  discarded  after  use. 

The  technique  of  local  anaesthesia  requires  the 
proper  introduction  of  the  needle,  the  correct 
method  of  injecting  the  anaesthetic,  and  waiting  a 
sufficient  length  of  time,  until  the  anaesthetic  has 
affected  the  nerves  supplying  the  part  to  be  oper- 
ated upon. 

After  the  anaesthetic  has  been  prepared,  the 
syringe  is  filled  and  the  needle  attached.  Air 
bubbles  within  the  barrel  are  expelled  by  hold- 
ing the  syringe  upward,  and  the  air  will  then  raise 
to  the  top;  by  slowly  expressing  a  few  drops  of 
solution  through  the  needle,  the  advancing  liquid 
will  force  out  the  air.  Air  injected  into  the  tissues 
may  produce  pain.  It  is  better  to  fill  a  syringe 
before  attaching  the  needle,  as  if  more  anaesthetic 
solution  is  required  the  operator  (once  having  ac- 
quired the  habit)  is  less  apt  to  place  the  bloody 
needle  into  the  solution,  and  thus  taint  the  inside 
of  the  syringe,  as  some  of  the  material  adhering 
to  the  needle,  leaving  the  tissues,  will  be  set  free 
in  the  solution.  Tf  a  platinum  needle  is  used,  heat- 
ing it  in  the  flame  will  sterilize  it,  of  course. 

If  a  needle  is  removed  or  attached  to  the 
syringe,  it  should  be  handled  with  forceps,  as  the 
fingers  destroy  its  sterility. 

Having  filled  tli"  syringe  and  expelled  air  bub- 
bles which  may  be  present,  it  is  grasped  like  a  pen- 


166  Local  Anjesthesia 

holder,  and  the  tissues  having  been  iodized,  the 
needle  is  thrust  into  the  gum  until  bone  is  reached. 
The  flattened  portion  of  the  needle  should  always 
lie  parallel  to  the  bone.  If  inserted  otherwise,  the 
needle  is  apt  to  bend  and  break  (Fig.  87). 

The  needle  should  not  be  inserted  at  the  gingival 
border,  but  higher  up  toward  the  apex  of  the  root 
(Fig.  88). 


Fig.  80 
Showing  Porous  Character  of  Upper  Jaw,  in  Posterior  Portion 
— Shows   Tuberosity    of    Upper   Maxilla — Also   Demonstrates   the 
Dense  Character  of  the  Mandible  in  the  Posterior  Portion  of  the 
Body. 

When  the  bone  is  reached  the  liquid  should  be 
slowly  and  evenly  injected  subperiostially,  and  the 
area  then  massaged.  Wheals  should  not  be 
formed ;  if  such  is  the  case,  the  liquid  has  not  been 
injected  deep  enough  and  has  spread  just  below 


Infiltration 


167 


Coxtt^L 


^*w 


Fig.  ss 


Shows  Correct  and   Incorrect  Method  of  Inserting  Hypodermic 
Needle. 


the  superficial  layer  of  mucous  membrane.  Suffi- 
cient time  should  elapse  to  allow  absorption  to 
take  place,  as  the  resulting  anaesthesia  is  not  due 


168 


Local  Anaesthesia 


to  pressure,  but  induced  by  the  solution  reaching 
the  nerve  endings  through  absorption.  This  means 
about  three  to  five  minutes.  The  efficacy  of  the 
anaesthesia  can  be  tested  by  pricking  the  infiltrated 
area  with  the  hypodermic  needle.  After  the  su- 
perficial area  is  anaesthetized  we  have  to  wait  until 
the  solution  traverses  the  alveolar  process  to  the 
pericementum.  Fig.  89  shows  the  proper  method 
of  inducing  infiltration  anaesthesia.  Infiltration 
anaesthesia  can  be  used  with  good  success  in  those 
areas  of  the  maxillae  which  are  spongy  and  pre- 
sent many  small  foramina ;  but  in  those  localities 
where  the  bone  is  dense,  as  in  the  molar  and  bi- 


Fig.  89 
Infiltration  Anaesthesia  in  Anterior  Portion  of  Upper  Jaw.  Note 
Position  of  Syringe. 


Infiltration 


169 


Fig.  90 
Infiltration  Anaesthesia  on  Lingual  Aspect  of  Lower  Molar  Region 

cuspid  region  of  the  mandible,  the  infiltration 
method  will  not  be  successful,  and  we  have  to  re- 
sort to  the  conductive  method.  Another  point  to 
remember  is  that  we  may  not  infiltrate  any  in- 
fected area,  as  septic  material  will  be  forced  into 
adjacent  tissues,  and  a  very  poor  or  no  anaesthe- 
sia is  obtained.  The  infiltration  method  has  its 
decided  limitations,  and  as  conductive  anaesthesia 
will  do  all  that  which  infiltration  anaesthesia  will 
accomplish,  it  is  far  superior  in  efficacy. 

The  advantages  and  disadvantages  of  the  two 
methods  are: 


170 


Local  Anaesthesia 


Fig.  91 
Anaesthesia  by  Infiltration  in  Lower  Jaw,  Canine  Region 


Infiltration: 

1.  Lasts  a  short  time. 

2.  Anaesthesia    confined 

to  injected  area. 


Infected   tissue   can- 
not be  anaesthetized. 


More  frequent  injec- 
tions required. 


Conductive: 

1.  Lasts  longer. 

2.  Anaesthesia     extends 

throughout  whole 
area  of  nerve  sup- 
ply- 

3.  By  blocking  off  the 

nerve  at  its  forami- 
nal  exit,  distal  in- 
fected areas  are  an- 
aesthetized. 

4.  Fewer  injections  re- 

quired. 


Local  and  Conductive  171 

5.  More    extensive    and 

larger  operations 
can  be  performed. 

6.  The  anaesthesia  last- 

ing so  much  longer, 
post  traumatic  pain 
is  greatly  reduced. 

7.  Less    of    the    actual 

drug  required. 


VI 

Anatomical  Considekations 

The  anatomical  considerations  in  this  chapter 
should  merely  serve  to  recall  to  the  reader's  mind 
the  most  important  landmarks  essential  for  the 
practice  of  local  anaesthesia;  for  more  careful 
study,  which  is  essential,  the  student  is  referred  to 
special  works  on  anatomy.  The  upper  jaw  is  sup- 
plied by  the  superior  maxillary  nerve,  the  second 
division  of  the  trigeminus,  and  the  upper  teeth 
can  be  divided  into  three  groups,  according  to 
their  nerve  supply. 

The  central  and  lateral  incisor  and  canine  teeth 
are  supplied  by  the  anterior  superior  dental 
branch;  the  bicuspids,  by  the  middle  superior  den- 
tal branches,  and  the  molars  by  the  posterior  su- 
perior dental  branches  on  each  side. 

The  middle  superior  branches  communicate 
with  the  posterior  superior  dental  branches  by  a 
thickening  called  the  ganglion  of  Valentine,  and 
with  the  anterior  superior  dental  branches  by  an 
enlargement  called  the  ganglion  of  Bochdalek. 

The  anterior  superior  dental  branch  is  given 
off  from  the  superior  maxillary  nerve  just  before 
its  exit  from  the  infraorbital  foramen. 

172 


Anatomy  173 

The  middle  superior  dental  branch  is  given  off 
from  the  same  nerve  in  the  back  part  of  the  infra- 
orbital canal,  and  runs  downward  and  forward  in 
a  canal  in  the  outer  wall  of  the  antrum. 

The  posterior  superior  dental  branches  arise 
from  the  trunk  of  the  superior  maxillary  nerve 
just  as  it  enters  the  infraorbital  canal,  running 
downward  on  the  tuberosity  of  the  upper  maxilla, 
entering  the  posterior  dental  canals  on  the  zygo- 
matic surface  of  the  bone. 

In  order  to  anaesthetize  these  various  branches 
we  have  to  block  them  as  they  enter  or  leave  their 
bony  foramina.  Thus  to  reach  the  anterior  supe- 
rior dental  branch  we  have  to  make  an  injection 
at  the  infraorbital  foramen;  this  will  anaesthetize 
the  central,  lateral  and  canine  teeth,  and  by  osmo- 
sis via  the  ganglion  of  Bochdalek  affect  sensation 
in  the  middle  superior  dental  branch,  and  there- 
fore anaesthetize  the  biscupids  more  or  less. 

If  the  molars  are  to  be  anaesthetized,  the  poste- 
rior superior  dental  branch  must  be  injected  at 
the  tuberosity,  blocking  off  the  nerves  as  they 
enter  the  posterior  dental  canals.  If  this  is  done, 
in  the  majority  of  cases  the  middle  branch  is  also 
affected  by  osmosis  through  the  ganglion  of  Val- 
entine, thus  also  ana>sthetizing  the  bicuspids. 

As  the  superior  Middle  Dental  Branches,  sup- 
plying the  bicuspids,  anastomose  with  both  the 
posterior  and  anterior  dental  nerves,  the  anaes- 


174 


Local  Anaesthesia 


(interior 
Subeosv    - 


Supeno^  J1o,».'lWvij  Wer»a 


"T«w   "&** 


Ovm^f 


Figures  92  and  93 
Showing  the  Nerve  Supply  of  the  Various  Groups  of  Teeth.  The 
Posterior  Superior  Dental  Nerve  Supplying  the  Molars,  the  Ante- 
rior Superior  Dental  Nerve  Supplying  the  Central  and  Lateral,  as 
Well  as  the  Canine  and  the  Middle  Superior  Dental  Nerve  Sup- 
plying the  Bicuspids.  Also  shows  the  Anastemoses  Between  the 
Different  Branches. 


Anatomy 


175 


Fig.  94 
Shows  the  Posterior  Superior  Dental  Nerve,  Entering  the  Supe- 
rior Maxilla  upon  the  Tuberosity  by  the  Posterior  Dental  Canals. 


Fig.  95 
Shows  the  Nerve  Supply  of  the  Hard  Palate.  The  Naso-Palatine 
Nerve  Emerging  Through  the  Anterior  Palatine  Canal,  Supplying 
the  Anterior  Portion  of  the  Palate,  the  Anterior  Palative  Nerve 
Emerging  Through  the  Posterior  Palatine  Canal,  Supplying  the 
Posterior  Portion  of  the  Palate. 


thetization  of  the  bicuspids  sometimes  becomes 
difficult  by  the  conductive  method.  If  we  inject 
the  anterior  branch  we  get  anaesthesia  in  the  first 
bicuspid,  sometimes  also  in  the  second  premolar; 
injecting  the  tuberosity,  the  second  bicuspid  may 


176  Local  Anesthesia 

or  may  not  be  affected.  It  therefore  may  be  neces- 
sary to  inject  the"  tuberosity,  posterior  dental 
canal  and  infraorbital  foramen  to  produce  the 
required  result.  In  preference  to  such  compli- 
cated injection,  the  infiltration  of  both  bicuspids 
both  on  the  palatine  and  facial  aspect  will  be  the 
simpler  method. 

The  hard  palate  is  supplied  by  two  nerves :  the 
naso-palatine,  one  of  the  internal  branches  of  the 
spheno-palatine  ganglion,  which  nerve,  after  sup- 
plying part  of  the  nasal  fossae,  passes  downward 
and  forward,  entering  the  mouth  through  the  an- 
terior palatine  canal,  supplying  the  mucous  mem- 
brane behind  the  incisor  teeth. 

The  posterior  portion  of  the  palate  is  supplied 
by  the  anterior  palatine  nerve,  one  of  the  descend- 
ing branches  of  the  spheno-palatine  ganglion,  de- 
scending through  the  posterior  palatine  canal  and 
emerging  upon  the  hard  palate  through  the  ante- 
rior palatine  foramen  opposite  the  last  molar 
tooth,  supplying  the  palate  as  far  as  the  canine 
teeth,  the  gums,  mucous  membrane  and  glands 
of  the  palate  anastomosing  with  the  naso-palatine 
nerve. 

To  anaesthetize  the  anterior  part  of  the  palate 
the  naso-palatine  nerve  is  reached  as  it  leaves 
scarpas  foramina,  by  injecting  the  anterior  pala- 
tine canal;  and  to  anaesthetize  the  posterior  por- 
tion of  the  palate,  the  posterior  palatine  canal  is 


Anatomy  177 

injected,  opposite  the  last  molar  tooth,  which  will 
anaesthetize  the  anterior  palatine  nerve  (Fig.  95). 

The  anterior  superior  dental  branch  gives  off  a 
nasal  branch  supplying  the  mucous  membrane  of 
the  forepart  of  the  inferior  meatus  and  the  floor 
of  the  nose,  communicating  with  the  nasal 
branches  from  the  spheno-palatine  ganglion. 

For  this  reason  a  more  complete  anaesthesia  in 
the  anterior  part  of  the  jaw  can  be  obtained  by 
placing  a  tampon  saturated  with  the  anaesthetic 
solution  into  the  anterior  nares.  In  injecting 
about  the  infraorbital  foramen,  besides  producing 
anaesthesia  in  the  anterior  superior  dental 
branches,  other  branches  of  the  superior  maxil- 
lary nerve  are  reached,  thus  affecting  the  nasal 
and  labial  branches,  producing  an  anaesthesia  in 
the  upper  lip  and  sometimes  extending  to  the  side 
of  the  nose. 

The  lower  jaw  or  mandible  is  supplied  by  the 
inferior  maxillary  or  mandibular  nerve,  the  third 
branch  of  the  trigeminus. 

It  distributes  branches  to  the  teeth  and  gums  of 
the  lower  jaw,  the  lower  part  of  the  face  and  lip, 
the  muscles  of  mastication,  the  integument  of  the 
temple  and  external  ear,  as  well  as  the  tongue. 

Its  largest  branch,  the  inferior  dental  nerve,  is 
of  greatest  interest  to  the  dentist,  as  this  branch 
supplies  all  lower  teeth  with  sensation.  It  passes 
downward  with  the  inferior  dental  artery  beneath 


178  Local  Anesthesia 

the  external  pterygoid  muscle  and  then  between 
the  internal-lateral  (spheno-mandibular)  liga- 
ment and  the  ramus  of  the  jaw  to  the  dental  fora- 
men. It  then  enters  the  mandibular  canal  lying 
beneath  the  teeth  as  far  as  the  mental  foramen, 
where  it  divides  into  the  incisor  and  mental 
branches,  the  former  supplying  the  canine  and  in- 
cisor teeth,  the  latter  the  skin  of  the  chin  and  mu- 
cous membrane  of  the  lower  lip.  These  branches 
arborize  with  the  facial  nerve,  and  for  that  reason 
we  frequently  note  a  drooping  ot  the  facial 
muscles  after  mandibular  injections. 

The  molars  and  bicuspids  are  supplied  by 
branches  given  off  from  the  mandibular  canal. 

The  lingual  nerve  supplies  the  papillae  and  mu- 
cous membrane  of  the  anterior  two-thirds  of  the 
tongue,  and  lies  beneath  the  external  pterygoid 
muscle,  very  near  and  on  the  inner  side  of  the 
inferior  dental  nerve;  in  fact,  it  sometimes  is 
joined  to  it  by  a  branch.  It  communicates  with 
the  inferior  dental  and  hypoglossal  nerves,  the 
submaxillary  ganglion  and  with  the  facial  nerve 
through  the  chorda. 

The  proximity  of  the  lingual  nerve  to  the  infe- 
rior dental  nerve  explains  why  in  injecting  the 
mandibular  nerve  anaesthesia  of  one-half  of  the 
tongue  is  obtained,  and  also  the  reason  for  not 
getting  anaesthesia  on  the  lingual  aspect  of  the 
alveolus,  when  the  lips  and  facial  aspect  may  be 


Anatomy  179 

devoid  of  sensation.  Some  branches  of  the  lin- 
gual contribute  to  the  nerve  supply  of  the  lingual 
aspect  of  the  alveolar  process. 

The  buccal  or  buccinator  nerve  supplying  the 
facial  aspect  of  the  mucous  membrane  in  the  molar 
and  bicuspid  region  must  be  remembered,  and 
it  may  have  to  be  blocked  off  separately  to  get  per- 
fect anesthesia.  Williger,  of  Berlin,  advocates  a 
separate  injection  into  the  mucous  membrane  of 
the  cheek  below  Stenson's  duct;  the  author,  how- 
ever, finds  that  an  infiltration  in  the  region  of  the 
second  molar  is  sufficient  to  produce  the  desired 
effect.  In  fact,  in  the  majority  of  mandibular  in- 
jections, if  properly  done,  no  second  injection  of 
any  kind  is  required. 


VII 

The  Technique  of  Conductive  Anaesthesia 

The  Mandibular  Injection 

In   order  to  practice  conductive   anaesthesia,   or 

nerve  blocking,  it  is  essential  to  remember  those 

landmarks  which  will  enable  the  operator  to  lo- 


Fig.  96 
a.  Coronoid  Process ;  b.  Condyloid  Process ;  c.  Sigmoid  Notch ; 
j.  Body  of  Mandible;  k.  Ramus;  1.  Angle;  e.  Mental  Foramen; 
g.  Mylohyoid  Ridge,  Terminating  as  Mylo-hyoid  or  Internal 
Oblique  Line ;  d.  External  Oblique  Line ;  h.  Trigonum  Retromolare, 
formed  by  the  External  and  Internal  Oblique  Lines  and  the  Distal 
Surface  of  the  Last  Molar  Tooth;  rT~|  Lingula,  the  Bony  Spine 
directly  above  the  Inferior  Dental  Foramen  f.  to  show  the 
Foramen  and  Lingula  to  better  advantage,  the  Lingula  has  been 
shaded  with  ink. 

180 


Mandibular  Injection 


181 


cate  the  foramina  transmitting  the  nerves  to  be 
anaesthetized.  In  the  mandible  or  lower  jaw  we 
have  to  bear  in  mind  the  inferior  dental  foramen 
(Fig.  96),  and  the  mental  foramen  (Fig.  96).  The 
inferior  dental  foramen  is  found  by  placing  the 
index  finger  on  the  facial  aspect  of  the  alveolar 
process  and  palpating  for  the  external  oblique 
line  (Fig.  97).    Having  located  this,  the  finger  is 


slowly  passed  backward  and  upward  along  the  ex- 
ternal oblique  line  until  the  anterior  border  of  the 
ramus  is  plainly  felt.  The  patient  is  then  directed 
to  relax  the  muscles  by  slowly  shutting  his  mouth 


182  Local  Anesthesia 


Showing  Finger-Tip  Placed  in  the  Right  Retromolar  Triangle. 
The  Finger  Is  Slightly  Tilted. 


half  way.  The  object  of  this  relaxation  is  to  be 
certain  that  the  operator  is  actually  following  the 
bone  and  not  palpating  the  internal  lateral  liga- 
ment, which  in  some  cases  when  put  on  the  stretch, 
when  the  mouth  is  open,  may  be  mistaken 
for  the  bone.  When  the  muscles  are  re- 
laxed, in  shutting  the  mouth  the  ligament  also 
relaxes  and  is  pushed  out  of  the  way.  After  the 
finger  has  followed  the  external  oblique  line,  the 
tip  is  placed  behind  the  last  molar,  and  the  mylo- 
hyoid ridge  is  palpated.  The  finger-tip  is  then 
slightly  tilted  lingually,  and  placed  in  the  triangu- 
lar space  formed  by  the  external  and  internal 
oblique  lines,  and  the  distal  surface  of  the  last 


Ma  xdibular  Inj ectiox 


183 


Fig.  99 
Finger  in   Retromolar  Triangle  in  the  Mouth ;    the  Cheek  and 
Lips  Are  Retracted  to  Show  the  Finger  in  Position. 


molar.  This  space  is  known  as  the  retromolar 
triangle  or  trigonum  retromolare  (Fig.  98). 

The  finger  having  been  placed  in  the  retromolar 
triangle  tilting  lingually  (Fig.  99),  the  syringe, 
being  held  in  the  right  hand  like  a  penholder,  is 
now  introduced  into  the  mouth,  that  the  barrel  is 
placed  across  the  canine  or  first  bicuspid  of  the 
opposite  side,  and  the  needle  point  rests  just  above 
the  nail  of  the  index  finger  of  the  left  hand  (Fig. 
LOO). 

The  point  is  thrust  quickly  through  the  mucous 
membrane  till  it  strikes  tin-  bone;  this  will  give  us 


184 


Local  Anaesthesia 


Fig.  100 

Showing  Position  of  Index  Finger  in  Retromolar  Triangle,  Right 
Hand  Holding  Syringe;  the  Instrument  Is  Held  Like  a  Pen-holder 
and  Placed  Diagonally  Across  the  Dental  Arch,  One  End  Crossing 
the  Bicuspid  Region,  the  Needle  About  to  Pierce  the  Mucous  Mem- 
brane 1  cm.  Above  the  Morsal  Surface  of  the  Molar  Teeth,  Rest- 
ing on  the  Nail  of  the  Left  Index  Finger. 


a  level  just  about  1  cm.  above  the  morsal  surface 
of  the  molar  teeth  (Fig.  101). 

The  syringe  is  now  rotated  toward  the  side,  to 
be  anaesthetized,  the  needle  point  never  losing  its 
contact  with  the  ramus  (Fig.  102). 


Mandibular  Injection 


185 


Fig.  101 

Shows  Position  <>f  Syringe,  After  Mucous  Membrane  Has  Been 
Pierced  and  Index  Finger  Withdrawn. 


186 


Local  Anesthesia 


Fig.  102 
Shows  Position  of  Syringe  After  It  Has  Been  Rotated  Toward 
the  Side  to  Be  Anaesthetized,  Just  Prior  to  Thrusting  the  Needle 
Along  the  Lingual  Aspect  of  the  Ramus. 

In  bringing  the  syringe  around  from  the  left 
towards  the  right  side,  the  instrument  describes 
an  arc,  as  shown  in  Fig.  103. 


Fig.  103 
A.  B.  Indicates  the  Position  of  the  Syringe  as  the  Needle  Is 
Thrust  Through  the  Mucous  Membrane,  Striking  the  Ramus ;  C.  D. 
Shows  the  Position  of  the  Syringe  When  the  Operator  Is  Ready 
to  Slide  the  Needle  Along  the  Ramus  to  Enter  the  Spatium 
Pterygo-Mandibulare,  D.B.Arc  Described  by  Distal  End  of  Syringe. 


Mandibular  Injection 


187 


The  lingual  or  internal  surface  of  the  ramus  is 
now  slowly  palpated,  and  thereby  the  needle  slides 
along  the  bone,  gradually  approaching  the  inferior 
dental  foramen  (Fig.  104). 


Fig.  104 
Syringe  Brought  Around,  Just  Before  the  Needle  Is  Slid  Along 
tin-  Ramus;   Corresponds  to  Line  CD.  in  Fig.  103. 


Fig.  I  or, 
Making  the  Actual  Injection 


188  Local  Anesthesia 

When  the  needle  passes  the  lingula  mandibular 
the  contact  of  bone  is  lost,  and  we  have  entered 
the  spatium  pterygo-mandibulare. 

Our  needle  has  disappeared  almost  entirely. 
The  writer  now  employs  a  slight  lateral  move- 
ment, attempting  to  palpate  the  lingula,  and  then 
slowly  and  evenly  empties  the  contents  of  the 
syringe,  drawing  the  needle  slightly  in  and  out. 
By  the  lateral  and  in  and  outward  motion  the 
lingual  nerve  is  usually  anaesthetized. 


On  the  left  side  the  same  technique  is  employed, 
palpating  with  the  right  and  holding  the  syringe 
in  the  left  hand.  The  injection  can  also  be  made 
with  the  right  hand,  but  then  the  thumb  of  the  left 
hand  is  used  instead  of  the  index  finger,  and 
placed  in  the  trigonum  retromolare,  the  operator 
standing  at  the  side  or  behind  the  patient  (Figs. 
112,  113)  ;  otherwise  the  technique  is  identically 
the  same  as  executed  on  the  right  side. 


Tuberosity  Injection 

The  tuberosity  of  the  upper  maxilla  is  reached 
by  thrusting  the  needle  into  the  buccal  fold  oppo- 
site the  disto-buccal  root  of  the  second  upper  mo- 


189 


PLATE  I 


Fig.  106 
Palpating  Facial  Aspect  of  Alveolar  Process 


Fig.  107 
Placing  Index  Finger  in  Retromolar  Triangle 


PLATE  II 


190 


Fig.   108 
Placing  Syringe 


Fig.  109 

J'iciciiiL'  Minims  Membrane 


191 


PLATE  III 


FIG.  110 
Bringing  Syringe  Toward  Side  to  Be  Anaesthetized 


Fig.  Ill 
Entering   Spatium  Pterygo-Mandibulare   and   Emptying   Syringe 


PLATE  IV 


192 


Fig.  112 
Placing  Thumb  into  Retromolar  Triangle  on  Left  Side 


I'h..   113 
[ntroducing  Syringe  and    Piercing  Mucous   Membrane  of  I^'t't 
Side;  the  Other  Steps  Arc  Identical  as  Carried  Out  on  the  Other 
Side. 


Tuberosity  Injection 


193 


lar,  and  passing  it  upward  and  backward  (Fig. 
114).  The  needle  should  keep  in  contact  with  the 
bone. 


Fig.   114 
Making  Tuberosity  Injection 


Posterior  Palatine  Injection 

The  posterior  palatine  canal,  which  terminates 
upon  the  palate  opposite  the  third  molar  as  the 
anterior  palatine  foramen,  giving  exit  to  the  an- 
terior palatine  nerve,  is  reached  by  thrusting  the 
needle  into  the  palatine  mucous  membrane  about 
V-±-?,A  cm-  inside  (toward  the  median  line)  of  the 
third  molar.  In  many  subjects  there  appears  a 
tiny  depression  in  the  mucous  membrane  at  this 
site. 


194 


Local  Anesthesia 


Fig.  115 
Injecting  the  Posterior  Palatine  Canal 

By  injecting  the  tuberosity  and  blocking  off  the 
anterior  palatine  nerve,  the  three  molars  are  com- 
pletely anaesthetized.  The  palatine  surface  loses 
sensation  up  to  the  canine  tooth.  In  many  in- 
stances the  second  bicuspid  also  becomes  anaesthe- 
tized by  the  tuberosity  injection. 


Anterior  Palatine  Injection 

To  block  off  the  naso-palatine  nerve,  by  inject- 
ing the  anterior  palatine  canal,  the  needle  is  thrust 
into  the  posterior  aspect  of  the  incisive  papilla, 
which  is  situated  about  y2  cm.  posterior  to  the 
central  incisors.  The  needle  is  directed  upward 
and  backward  (Fig.  116).    About  seven  drops  are 


Infraorbital  Injection 


195 


used  for  this  injection;  this  will  anaesthetize  the 
anterior  portion  of  the  hard  palate  in  the  incisal 
region.   (See  Cases  72,  99,  in  Anaesthesia  Reports.) 


Fig.  110 
Injecting  the  Anterior  Palatine  Canal 


Infraorbital  Injection 

To  find  the  infraorbital  foramen,  palpate  the 
superior  border  of  the  orbit  and  locate  the  supra- 
orbital notch;  the  infraorbital  foramen  is  found 
below  the  inferior  border  of  the  orbit  in  a  fairly 
straight  line  with  the  notch;  place  the  index  fin- 
ger on  the  lower  border  of  orbit,  introduce  the 
thumb  into  the  vestibule  of  the  mouth  and  lift  up 
lh'-  upper  lip,  drawing  it  upward  and  forward. 
The  needle  is  now  thrust  into  the  muco-buccal  fold 
opposite  the  index  finger,  which  will  be  found  just 


196 


Local  Anesthesia 


Fig.  117 
Injecting  Infraorbital   Foramen  on  Skull.     Note   Direction  of 
Needle  and  Syringe. 


Fro.  Hi 
Making  Infraorbital  Injection.     Note  Position  of  Left  Hand 


Mental  Injection 


197 


about  above  the  canine  tooth.  Inject  drop  by  drop, 
as  you  go  along,  until  you  feel  the  foramen  with 
the  needle,  depositing  about  1  ccm.  at  the  opening 
of  the  canal.  A  little  massage  will  drive  the  anaes- 
thetic into  the  foramen.  (See  Cases  72,  80,  89,  92, 
in  Anaesthesia  Reports.)     (Figs.  117-118.) 

Mental  Injection 

The  mental  foramen  is  reached  by  drawing  the 
lip  down  with  thumb  and  index  finger  and  thrust- 


FlG.    II!) 

Showing  Mental  Injection  on  Skull.     Note  Location  of  Foramen 
and  Dired  ion  of  Needle. 


198 


Local  Anesthesia 


Fig.  120 
Injecting  the  Mental  Foramen 


ing  the  needle  through  the  mandibular  mucous 
membrane  fold  between  the  two  bicuspids  ;  slightly 
advancing  the  needle  point  toward  the  first  bicus- 
pid will  cause  it  to  enter  the  mental  foramen  (Fig. 
120).  About  1  ccm.  of  solution  should  be  injected. 
About  y2  ccm.  injected  on  the  lingual  aspect  will 
anaesthetize  the  mucous  membrane  and  perios- 
teum. This  will  anaesthetize  the  two  bicuspids  and 
canine.  If  this  injection  is  made  on  both  sides,  the 
six  anterior  teeth  are  completely  anaesthetized. 
(See  Case  47  in  Anaesthesia  Reports.) 


VIII 

Indications  and  Contraindications  for  Local 
Anaesthesia 

Local  anaesthesia  is  indicated  in  dental  and  oral 
surgery  in  almost  all  cases. 

The  exceptions  being  the  following : 

1.  Hysterical  patients,  or  such  who  are  ex- 
tremely excited,  and  this  state  of  excitement  can- 
not be  controlled  by  the  administration  of  seda- 
tives ;  these  cases  are  better  fit  for  general  anaes- 
thesia. 

2.  Patients  who  exhibit  an  idiosyncrasy  against 
local  anaesthetics.  By  this  the  writer  does  not 
mean  the  patient  who  says,  "I  want  gas,  or  I  want 
ether,"  but  cases  who  actually  show  an  unusual 
physiologic  reaction  against  the  drugs  used.  The 
writer  has  never  seen  or  heard  of  a  case  of  idio- 
syncrasy against  novocain.*  The  patient  who 
wants  this  or  wants  that  must  be  given  to  under- 
stand that  he  has  no  choice  in  the  matter,  but  that 

*By  this  the  author  means  that  he  lias  never  seen  any  case 
which  exhibited  alarming  symptoms  after  the  use  of  Novocain. 
He  has  mel  cases  where  the  anaesthesia  was  unsatisfactory;  the 
patients  upon  inquiry  stated  that  cocaine  used  on  previous  occa- 
sions either  had  made  them  ill  or  failed  to  produce  any  anaesthe- 
sia at  all  or  both.  Dr.  Geo.  Rice  of  New  York  related  a  similar 
case  to  the  author,  wherein  he  could  not  obtain  complete 
anaesthesia.  The  writer  will  use  Novocain  in  cases  where  lie  would 
refuse  to  employ  cocaine. 

199 


200  Local  Anaesthesia 

the  selection  of  the  anaesthesia  rests  with  the 
operator.  Some  of  the  writer's  most  enthusiastic 
patients  are  those  who  at  first  objected  to  injec- 
tions. 

Patients  who  cannot  tolerate  cocaine  are  not 
necessarily  unsuitable  for  novocain  anaesthesia; 
we  must  remember  that  novocain  is  a  great  deal 
less  toxic  than  cocaine.  In  employing  novocain- 
suprarenin  anaesthesia  the  operator  must  bear  in 
mind  that,  although  novocain  itself  does  not  af- 
fect the  cardiac  function  or  circulation  in  general, 
or  the  respiratory  function,  suprarenin  raises  the 
blood  pressure.  In  old  people  and  patients  whose 
blood  pressure  is  high,  as  those  suffering  from 
arteriosclerosis,  it  is  wise  to  employ  less  supra- 
renin. 

However,  we  must  not  be  blind  to  the  fact  that 
there  are  individuals  who  possess  idiosyncrasies 
against  certain  drugs,  and  undoubtedly  cases  will 
present  who  react  abnormally  to  novocain  in  spite 
of  its  low  toxicity.  There  are  persons  who  can't 
eat  strawberries,  and  others  who  can't  partake  of 
certain  fish,  although  both  are  articles  of  food 
considered  beneficial  and  nourishing.  We  simply 
have  to  watch  our  patients  carefully,  and  if  any 
untoward  symptoms  present,  the  further  use  of 
the  drug  is  contraindicated.  The  writer,  who  has 
used  novocain  in  several  thousand  cases,  has  not 
met  with  any  direct  idiosyncrasy  against  novocain, 


Contraindications  201 

but  he  recalls  two  cases  who  suffered  from  slight 
symptoms  of  poisoning  after  but  normal  injec- 
tions. 

Children,  whose  cooperation  is  difficult  to  obtain 
at  times,  prove  unsuitable  subjects.  For  extrac- 
tions no  anaesthetic  at  all,  or  a  short  general  anaes- 
thesia, will  be  the  methods  of  choice  in  such  in- 
stances. 

3.  Another  contraindication  for  local  anaesthesia 
is  the  presence  of  infection  in  the  area  where  the 
injection  is  made;  this  does  not  imply  the 
field  of  operation,  but  the  area  which  the  needle 
traverses.  Thus  we  can  induce  mandibular  anaes- 
thesia in  all  cases,  except  where  there  is  infec- 
tion in  the  third  molar  region,  as  infected  mate- 
rial may  be  carried  into  the  spatium  pterigo  man- 
dibulars, and  thus  serious  infection,  neuritis, 
arteritis  or  phlebitis  in  the  mandibular  area,  or 
even  infection  of  the  deeper  structures,  may  be 
produced.  In  other  words,  mandibular  anaesthe- 
sia can  be  induced  for  all  cases  in  the  lower  jaw 
excepting  when  the  third  molar  is  abscessed,  or 
when  a  complete  trismus  is  present,  preventing 
the  location  of  the  inferior  dental  foramen.  Anal- 
ogous conditions  exist  in  the  upper  jaw. 

From  this  we  learn  that  even  conductive  anaes- 
thesia has  its  limitations,  and  any  operator  who 
would  say  that  he  has  no  use  for  inhalation  anaes- 
thesia at  all  is  either  limiting  his  work  to  suitable 


202  Local  Anaesthesia 

cases  or  he  is,  to  say  the  least,  narrow-minded. 
To  perfectly  master  any  method  means  not  only 
"how  to  use  it,"  but  also  to  know  "when  not  to 
use  it."  There  is  no  inflexible  rule  in  medicine, 
as  we  are  working  on  vital  tissues  and  organs, 
which  are  controlled  by  a  nervous  system,  whose 
condition  is  never  alike  in  two  individuals. 

Local  anaesthesia  proves  one  of  the  greatest 
blessings  ever  given  to  medicine  and  dentistry,  but 
we  must  know  how  to  use  this  gift. 

What  more  can  we  demand  of  any  method  of 
anaesthesia  that  insures  us  in  the  majority  of 
cases: 

1.  Painless  cavity  preparation. 

2.  Painless  pulp  removal. 

3.  Painless  tooth  extraction. 

4.  Painless  oral  surgery. 

The  writer,  who  limits  his  practice  to  the  last 
two,  has  been  able  to  cut  down  his  hospital  cases 
to  a  small  percentage,  operating  most  cases  in  his 
office  under  conductive  anaesthesia. 


IX 

Inhalation  Anaesthesia  versus  Conductive 
Anaesthesia 
It  is  true  many  operations  can  be  performed  by 
the  induction  of  analgesia  and  anaesthesia  through 
the  use  of  nitrous  oxide  and  oxygen ;  this  method, 
however,  does  not  do  away  with  traumatic  shock 
and  requires  cumbersome  apparatus.    Besides,  no 
one  can  pay  close  attention  to  the   anaesthesia, 
which  is  essential  to  get  a  good  result  and  at  the 
same  time  do  an  operation  which  demands  atten- 
tion to  minute  details,  and  all  operations  require 
that,  if  we  are  fair  to  our  patients.     If  both  are 
attempted  by  one  individual,  either  anaesthesia  or 
operation  is  bound  to  suffer,  and  the  result  cannot 
be  perfect.     If  an  operator  attempts  to  do  any- 
thing surgical,  and  during  the  anaesthesia  his  ap- 
paratus requires  adjustment,  which  is  bound  to 
happen,  he  will  soil  his  apparatus  and  destroy  the 
asepsis  of  his  hands  by  handling  the  anaesthetic 
machine.    Besides,  this  dual  role  is  bound  to  tell 
on  the  operator's  nerves.    Further  assistance  is, 
therefore,  required,  as  well  as  the  highest  skill  in 
general  anaesthesia. 

Tie-  apparatus  is  difficult  to  transport  for  cases 
to  be  operated  upon  outside  of  the  office.    Analge- 

203 


204  Local  Anaesthesia 

sia  is  frequently  unsatisfactory,  and  therefore 
very  trying  to  the  patient.  There  are  very  few 
men  who  can  accomplish  with  nitrous  oxide  oxy- 
gen what  almost  anybody  can  do  with  conductive 
anaesthesia,  provided  the  fundamental  principles 
of  asepsis  and  a  little  anatomical  knowledge  are 
employed. 

The  use  of  other  inhalation  anaesthetics  besides 
nitrous  oxide  or  nitrous  oxide  and  oxygen  is  dan- 
gerous, in  spite  of  statistics.  Ether  ranks  directly 
after  nitrous  oxide  in  safety.  How  many  men  use 
ether  in  their  offices  f  The  safest  of  all  inhalation 
anaesthetics  is  nitrous  oxide  and  oxygen,  but  it  is 
the  most  difficult  to  use,  with  anything  like  uni- 
form success.    Success  in  anaesthesia  means : 

1.  Safety  to  patient. 

2.  No  ill  after-effects. 

3.  Actual  painless  operation. 

The  first  two  are  frequently  accomplished;  the 
latter  frequently  overlooked,  as  the  operator  does 
not  feel  the  pain.  The  most  reliable  information 
on  the  last  point  can  only  be  obtained  from  the 
patient.  In  a  large  percentage  of  cases  where  an- 
algesia is  employed  patients  will  say,  "I  knew 
what  was  going  on ;  I  could  not  move  or  talk,  but 
I  felt  pain,"  and  pain  means  shock. 

The  writer  does  not  mean  to  imply  that  an  ideal 
analgesia  or  anaesthesia  cannot  be  obtained  by  in- 
halation methods,  but  he  means  to  state  that  in 


Inhalation  versus  Conductive  205 

many,  many  cases  the  operator  does  not  meet  with 
ideal  results.*  It  is  easier  and  less  harmful  to  the 
patient  and  less  difficult  for  the  operator  to  obtain 
ideal  results  with  conductive  anaesthesia,  properly 
induced.  Failures  will  be  met  with  by  all  meth- 
ods ;  nothing  is  perfect  in  nature.  If  it  were,  there 
would  be  no  need  for  physicians,  surgeons  or 
dentists. 

Another  disadvantage  of  inhalation  anaesthesia 
is  the  necessity  of  administering  it  as  long  as 
lessened  or  abolished  sensation  is  required.  In 
nerve  blocking  with  novocain,  anaesthesia  is  main- 
tained for  a  long  time,  usually  for  the  whole  length 
of  the  operation  after  anaesthesia  has  once  been 
induced. 

The  advantages  of  conductive  anaesthesia  over 
general  anaesthesia  are: 

1.  Conductive  anaesthesia  (novocain)  is  less 
harmful  to  the  patient  than  the  continuous  admin- 
istration of  an  inhalation  anaesthetic. 

2.  There  is  no  cumbersome  apparatus  required. 

3.  The  anaesthesia  lasts  a  longer  time. 

4.  There  are  no  unpleasant  after-effects. 

5.  The  patient,  not  being  unconscious,  can  as- 
sist the  operator. 

6.  Hemorrhage  is  easier  controlled. 

•See  Report  of  "Committee  on  Practice"  of  the  Dental  So- 
ciety  of  the  State  of  NCw  York  on  analgesia.  Dental  Cosmos, 
November,  lit  14;  page  1260. 


206  Local  Anaesthesia 

7.  Less  assistance  required  than  in  inhalation 
anaesthesia. 

8.  Blocks  off  not  only  painful  impulses,  but  also 
traumatic  shock. 

The  writer  advocates  the  use  of  conductive  an- 
aesthesia in  all  instances,  excepting  in  cases  where 
the  third  molars  are  abscessed.  In  simple  extrac- 
tions or  operations  which  can  be  executed  in  twen- 
ty to  thirty  seconds,  nitrous  oxide  or  nitrous  oxide 
and  oxygen  will  prove  more  expeditious  than  an- 
aesthesia by  the  conductive  method,  as  conductive 
anaesthesia  requires  from  ten  to  twenty  minutes' 
time  until  complete  cessation  of  pain  is  established. 
Small  children  are  probably  better  served  with  in- 
halation anaesthesia;  but,  in  the  main,  conductive 
anaesthesia  has  come  to  stay,  and  unquestionably 
will  almost  entirely  displace  inhalation  analgesia 
and  anaesthesia  in  dental  and  oral  surgery. 

If  nitrous  oxide  and  oxygen  is  used  for  longer 
operations,  it  should  be  administered  by  an  ex- 
pert and  combined  with  local  anaesthesia,  after  the 
method  advocated  by  Crile. 


X 

Shock  in  Oral  Surgery 

Crile  has  shown  that  shock  plays  an  important 
part  in  surgical  practice.  He  showed  that  the  ces- 
sation of  pain  by  inhalation  anaesthesia  does  not 
cut  otr  traumatic  shock  caused  by  cutting  tissue; 
also  that  the  preoperative  psychic  state  of  the  pa- 
tient produces  cerebral  disturbances — shock.  So 
that  in  operative  procedures  shock  is  caused  by: 

1.  Anxiety  of  the  patient. 

2.  Pain  felt  by  the  patient. 

3.  Traumatic  shock  by  cutting  tissue. 

In  ordinary  inhalation  anaesthesia,  when  the  pa- 
tient feels  no  pain,  only  one  source  of  shock  to  the 
brain  is  eliminated.  The  preoperative  psychic 
disturbance  is  allayed  by  the  administration  of 
sedatives — hypnotics  as  bromides,  valerian  and 
opiates. 

Traumatic  shock  can  only  be  done  away  with 
by  nerve  blocking;  that  is,  the  interposition  of  a 
drug  which  will  inhibit  impulses  along  the  nerve 
trunks.  For  this  purpose  he  employs  novocain. 
To  get  an  ideal  anaesthesia  he  employs  both  a  gen- 
eral  and  a  local  anaesthetic,  preceded  by  a  hypnotic. 
Thus  he  obtains  a  lack  of  sensation,  a  blocking  of 

207 


208  Local  Anesthesia 

afferent  impulses  and  reduced  cerebral  impres- 
sions. 

In  employing  nitrous  oxide  and  oxygen,  the 
safest  general  anaesthetic,  we  do  not  block  off  trau- 
matic shock,  nor  do  we  reduce  the  shock  caused  by 
apprehension  and  fear  on  the  part  of  the  patient. 

In  using  conductive  anaesthesia  preceded  by 
sedatives,  we  come  nearer  to  the  ideal  anaesthesia 
than  by  using  any  other  method. 

1.  Apprehension  and  fear  is  reduced  by  giving 
bromural,  or  in  extreme  cases  opiates. 

2.  By  nerve  blocking  we  not  only  cause  a  pain- 
less operation,  but  at  the  same  time  cut  off  im- 
pulses caused  by  traumatic  shock. 

It  can  be  readily  seen  that  analgesia  induced  by 
the  inhalation  of  N200  causes  a  certain  amount 
of  shock ;  and,  therefore,  conductive  anaesthesia  is 
the  method  of  choice  both  in  operative  and  surgical 
mouth  operations. 


XI 

Records  of  Conductive  Anaesthesias 

The  following  tables  show  the  record  of  one  hun- 
dred and  fifty  conductive  anaesthesias  (excepting; 
two  by  infiltration,  Cases  Nos.  149,  150)  in  oral 
surgical  and  operative  dental  cases,  both  in  pri- 
vate and  hospital  practice.  None  of  these  are 
selected  cases,  but  records  of  patients  just  as  they 
presented.  The  first  one  hundred  and  ten  anaes- 
thesias were  done  by  the  author,  both  at  home  and 
at  the  German  Hospital  in  New  York.  The  forty 
records  of  operative  dentistry  cases  were  obtained 
through  the  courtesy  of  Dr.  S.  W.  A.  Franken,  of 
New  York,  and  Dr.  H.  F.  Barge,  of  Long  Island 
City,  both  of  which  gentlemen  are  associated  with 
the  author  at  the  German  Hospital  Clinic. 

Key  to  Tables 

R.U.^right  side  upper  jaw. 
R.U.3.=right  upper  canine. 
L.U.=left  side  upper  jaw. 
L.U.8.=left  upper  third  molar. 
R.L.= right  side  lower  jaw. 
R.L.7.=right  lower  second  molar. 
L.L.=left  side  lower  jaw. 
L.L.4.=left  lower  first  bicuspid. 

209 


210  Local  Anaesthesia 

The  Roman  numerals  indicate  the  age  of  the  pa- 
tient :  VHI=patient  is  eight  years  old. 

The  amount  of  anaesthetic  solution  injected  is 
expressed  in  com. 

The  amount  of  novocain  used  in  a  case  is  ex- 
pressed in  grains. 

B.N.=buccal  nerve. 

Time  of  waiting=time  elapsed  between  injec- 
tion and  beginning  of  operation. 

A.P.C.=anterior  palatine  canal. 

P.P.C.=posterior  palatine  canal. 

Infilt.=innltration. 

Infra. o.f.=infraorbital  foramen. 

%  Nov.=per  cent,  of  novocain. 

l.E.S.=one  ccm.  of  solution  injected  on  each 
side. 

Nasal  t.=nasal  tampon. 


212 


Local  Anesthesia 


CONDUCTIVE   ANESTHESIA  IN 


OPERATION 

Extraction  unless 
otherwise  stated 


SITE  OF  INJECTION 


CQ   O 


_  c 
I  6 


°  c 

en  £ 

B  rt 

St3 

o  o 

a  v 

u>2 

H  o 


24 


Impacted  L.L.8 
Unerupted  L.  L.5 

L.L.7 

7. 

L. L.6  Pericementitis 

Removal  of  Tumor 

R.L.8.     aet.  VIII 

R.L.6.     aet.  XV 
L.L.6.     aet.  XIII 

Abscessed  L.L.6.  aet.  X 
L.L.6.     aet.  X 

Impacted  L.L.8 
L  L.6.     aet.  XIV 

Abscessed  L. L.6.    aet.  X 
R.L.6.     aet.  XVI 
R.L.6.     aet.  XIII 

Abscessed  L.L.6  aet.  IX 

R.L.6.     aet.  X 

L.L.6 

L.L.6.     aet.  XII 

L.L.6 

L.L.6.     aet.  XII 

R.L.6.     aet.  VIII 
Impacted  L.L.8 


2injections 
1  ccm.  each 


1 

1 
2injections 
1  ccm.  each 


1 

1 

1 

1 

1 

1 

1 

1 

2injections 
lecm.  each 

1 


3injections 
1  ccm.  each 


25  P.  Abscesed  R.L.7 


2  inj 

onea 


B.N.I 


B.N.I 


B.N.I 
B.N.I 
B.N.I 


B.N.  J 

B  N.  1 
B.N.I 
B.N.J 
B.N.| 
B.N.I 
B.N.I 
BN.{ 
B.N.J 
B.N.J 

BN.J 

B.N.J 

B.N.I 
BN.J 

B.N. J 
BN.J 

B.N.i 


B.N.  2 


B.N.I 


3 

H 

3 

n 

3 

2 
3 

2 

n 

n 

H 

2 

2 

H 

n 

2 
2 

n 

n 

H 
H 
H 

H 

n 
n 
n 

H 

n 

H 

n 

n 

2 

n 

2 

n 

H 

n 

H 

5 

i* 

2 

H 

*  Abbreviation  Br.  =  Bromural. 


Records 


213 


LOWER   JAW  IN  ORAL   SURGERY 


RESULT 


REMARKS 


Bromural 
gr.  X 

Bromural 
gr.  X 


Br.*gr.  X 
Br.  gr.  X 

Br.  gr.  X 


Black 
Coffee 


Br.  gr.  X 


Br.  gr.  X 


Perfect  Anaesthesia 
after  2  injections 

Patient  complained  of 
of  a  little  pain 


Perfect  Anaesthesia 

1st  Mandibular  failed 
2d,  perfect 


Perfect 
Perfect 
Perfect 
Perfect 
Perfect 
Perfect 
Perfect 
Perfect 
Perfect 


Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 
Anaesthesia 


Showed  symptoms  of 

Anaesthesia 
Showed  symptoms  of 

Anaesthesia 
Perfect  Anaesthesia 
Showed  signs  of 

Anaesthesia 
Perfect  Anaesthesia 
Showed  signs  of 

Anaesthesia 


Br.  gr.  X   Perfect  Anaesthesia 


Difficult  impaction,  had 
to  use  chisel  and  bur, 
operation  lasted  1  hour 

Difficultcase,  usedchisels 
and  burs,  operation 
lasted  45  minutes;  pa- 
tient marked  neurotic 


Child  cried,  stated  how- 
ever "had  no  pain" 


1st  Mandibular  failed 
Child  cried 
Child  cried 

Child  cried 


Child  cried 

Patient  said  he  felt  a 
little  pain,  but  not 
enough  to  mind  it 

1st  and  2d  Mandibular 
affected  the  lingual 
nerve  alone,  3d  injec- 
tion gave  a  fairly  good 
Anaesthesia 


214 


Local  Anaesthesia 


CONDUCTIVE     ANESTHESIA    IN 


OPERATION 


Extraction    unless 
otherwise  stated 


&.Z 


26 

27 
28 

29 
30 
31 

32 
33 
34 
35 
36 

37 
38 
39 
40 
41 

42 
43 
44 


45 
46 


47 


48 
49 
50 


P. 


L.L.6.     aet.  IX 
L.L.6.     aet.  VIII 
L.L.6.     aet.  XII 

L.L.6.     aet.  XIII 

L.L6. 

R.L.6.     aet.  XIII 

L.L.6.     aet.  XII 
R.L.6.     aet.  XII 
R.L.6.     aet.  XI 
R.L.7.6.5. 
L.L.8. 

L.L.6. 

R.L.8.7. 

R.L.6. 

R.L.6. 

L.L.4. 


L.L.8. 
R.L.7. 

R.L.8765. 


L.L.6. 


Unerupted  L.L.! 
Impacted  R.L.8. 


chronic  alveolar  abscess 
with  mental  fistula 


R.L.6.  Pulp  extirpation 

R.L.8. 

R.L.6.     aet.  XII 


1 

1 
1 

1 
1 
1 

1 
1 

1 

1 
using* 
2  ccm 

2 

1 

2 

2 


2 

2 

4 
2  ccm.  on 
each  side 

2 
5  separate 
injections 

7 


1  on 
R. 


1  on 

each 

side 

2 


B.N.4 
B.N.I 
B.N.f 

B.N.i 
B.N.I 
B.N 

B.N 

B.N 

B.N.I 

1 


B.N.I 
B.N.I 
B.N.I 

Ling'] 

*if 
B.N.  1 


B.N.I 
B.N. 2 


B.  N. 


2    1 
2   3 


*Author  employed  a  syringe  holding  2  ccm.  after  this;  also  2%  Solution  of  Novocain. 


Records 


215 


MANDIBLE 

IX     ORAL     SURGERY 

'« 

es  given 

■3 

V 

RESULT 

REMARKS 

o 

> 

- 

£ 

T3 

_= 

r- 

X                  P 

•Jll 

Perfect  Anaesthesia 

20 

20 

Showed  Symptoms  of  Anaes- 
thesia— child  cried. 

20 

" 

20 

" 

20 

Showed  Symptoms  of  Anaes- 
thesia— child  cried. 

20 

ii                   <• 

20 

Said:   "  Had  a  little  pain." 

25 

20 

Bro.  gr.  X 

"                   " 

20 

Bro.  gr.  X  .  . 

ii                   • » 

20 

Bro.  gr.  X  .  . 

.. 

20 

Bro.  gr.  X 1. . 

"                   " 

20 

Bro.  gr.  X  .  . 

"                   " 

20 

Bro.  gr.  X  .  . 

"                   " 

15 



ii                   * » 

20 

Bro.   gr.  X  .  . 

i< 

20 

"                   " 

20 

Bro.  gr.  X  .  . 

20 

Bro.  gr.  X 

.. 

20 

Bro.  gr.  X 

Got  no  anaesthesia  of  Inferior 

af- 

Dental Nerve.  Prof. Fischer 

ter 

later  obtained  perfect  An- 

ea. 

aesthesia  after  second  at- 
tempt. Found  anatomical 
abnormality  of  mandible. 

16 

Opened  chin  on  outside  and 
curetted  sinus  leading  into 
mouth.  Operation  lasted 
ihr. 

20 

Bro.  gr.  X 

" 

Patient  referred  by  her  den- 

20 

tist  to   have  pulp  removed 

20 

—  had     Arsenic  in  tooth  48 

hours.  —  Pericementitis  — 

pulpitis. 

Infiltra  tion  on  Lingual  Aspect. 


216 


Local  Anaesthesia 

CONDUCTIVE  ANESTHESIA  IN 


_ , 

a 

M 

J3 

6 

3 

o 

z 

o 

u 

V 

rf 

U 

. 

Eh 

51 

P. 

52 

P. 

53 

54 

55 

56 

P. 

57 

58 

P. 

59 

60 

P. 

61 

P. 

62 

63 

P. 

64 

65 

P. 

66 

67 

68 

69 

70 

OPERATION 


Extraction  unless 
otherwise  stated 


Fractured  R.  L.5 

R.L.7.6 

L.L.8 

Tumor  of  gum   extend- 
ing from  L.L.1-3 

Fractured  L.L.6 
Unerupted  Impacted 

L.L.8 

R.L.6 
Unerupted  Impacted 

L.L.5 


L.L  6 

L.L.8 

R.L.6.     aet.  VIII 

R.L.6.     aet.  VIII 
Fractured  L.L  7 

Abscessed  R.L.7 
R.L.8 

R.L.6.     aet.  XIII 
R.L.8 

R.L.6.     aet.  XIII 
R.L.8 
Impacted  R.L.8 


SITE  OF  INJECTION 


2  <«  52 

■2  s  2 

CO   o 

1-1  Mfc, 


2 

2  inj't's,  4 
2 


2injections 
4 


H 


2 

H 

2 
2 

2 
H 


—  a 

si 


1  ccm. 
ea.  side 
2 


B.N.I 
B.N.I 


^ccm. 
arou'd 
tumor 


B.N.I 


B.N.I 
B.N.  1 


N 


CT3 


M  C 


*  After  this  the  author  returned  to  the  use  of  1\^%  Solution  of  Novocain 


Records 
mandible  in  oral  surgery 


217 


a 
> 

8 
> 

n 
•o 
•j 

a 
.2 

RESULT 

REMARKS 

Bromural 

Perfect  Anaesthesia 

gr.  X 

Bromural 
gr   X 

.. 

First  Mandibular  failed 

.. 

Several  attempts  had  been 
made  to  remove  this  root 

Bromural 
gr.  X 

it                                  II 

Very  difficult  operation, 
used  chisels  and  burs, 
operation  50  min. 

Bromural 
gr.  X 

li                                   II 

First  Mandibular  failed,  sec- 
ond perfect,  difficult  case, 
used  chiselsand  burs, oper- 
ation lasted  over  1  hr. 

Bromural 
gr.  X. 

Bromural 
gr.  V 

.. 

Bromural 
gr.  X 

n                 <  * 

Bromural 
gr.  X 

■  1                                             >< 

218 


Local  Anjesthesia 


CONDUCTIVE  ANAESTHESIA  IN 


OPERATION 

Extraction  unless 
otherwise  stated 


SITE  OF  INJECTION 


c 

0 

o  S 

en  o 

-U 

°   E 

« 

S*13 

Firi 

fe 

<r? 

"S1-1 

0 

H 

£i"rt 
B-5 

g-g 


71 


72 


73 

74 
75 
76 

77 
78 
79 
80 
81 

82 
83 
84 
85 
86 
87 
88 

89 

on 

91 
92 

93 

94 
95 
96 
97 


Cyst  extending 
L.U.1-6 

Cyst.  L.U.3-4 


Cyst.  L.U.3 

L.U.6 

L.U.6 

Unerupted  R.U.3 

L.U.8 

L.U.5.8 

R.XT.6 

Tumor  R.U.3  region 

AlveoLotomy 

Fractured  R.U.8 
Impacted  R.U.8 
R.U.8 
R.U.8 
L.U.8 
L.U.8 
R.U.8 

j  Root  Amputation 
(  L.U.I 

Fractured  R.U.8 
L.U.4.6.8 
Malposed  R.U.3 
j  Necrosis  extending 
}  L.U.3-5 
Fractured  R.U.8 
R.U.8 

Abscessed  L.U.6 
Root  amputation 
R.U.2 


Nasal  t.* 
1 

Nasal  t. 
2 

Nasal  t 


Nasal  t. 


K 


Nasal  t 


Nasal  t. 
1 


5 

IK 

5 

1« 

2 

IK 

W 

IK 

m 

1% 

2 

IK 

*/2 

IK 

3 

IK 

2 

IK 

«K 

IK 

*K 

IK 

2% 

IK 

2K 

IK 

2 

2 

2 

2 

2 

2 

2H 

2 

2 

2 

2 

2 

2 

2 

3 

2 

2 

2 

2M 

2 

2 

2 

2 

2 

2 

2 

3 

2 

Tampons  of  Novocain  solution  in  nose;  also  1  ccm.  by  infiltration. 


Records 

UPPER  JAW  IN  ORAL  SURGERY 


219 


Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 


Br.  gr.  X 

Br.  gr.  X 
Br.  gr.  X 
Br.  gr.  X 

t  Kromural 


220 


Local  Anesthesia 


CONDUCTIVE     ANESTHESIA 

IN 

"rt 

« 

o 

"OT3 

>i 

U 

O 

«  c 

c 

OPERATION 

o 

"rt 

"rt 

3£ 

0"0 

g's 

33 

o  c 

Extraction  unless 
otherwise  stated 

V 

3 

H 

Ph 
_o 

V 

o 

Pn 

B 

O   A 
nl   k. 

ki    O 

<3 

Si! 
.5= 

o 
H 

"  o 
fc.  > 

u  o 
Pnfc 

—  o 

°* 
H25 

98 

P. 
P. 

R.U.8. 
Unerupted  L.U.3. 

1 

1 

2 
2 

2 
2 

* 
* 

99 

1 

1 

Nasal  t. 

100 

P. 
P. 
P. 

R.U.7.3. 
L.U.7. 
Abscessed  L.U.7. 

1 
1 
1 

1 
1 
1 

1 

3 
2 

2 

2 
2 

1 

101 

* 

10?, 

CONDUCTIVE    ANESTHESIA 

IN 

BOTH 

UPPER 

OPERATION 

Extraction  unless 
otherwise  stated. 

Site  of  Injection  in  Upper  Jaw. 

Site  of 

1 
H 

a 
a 
rt 
U 

"rt 
Ph 

o 

u 

o 
Ph 

c 
nl 

o 

"3 

Ph 

_o 
V 
c 

<; 

la 

o 
d 

c 

c 
o 
a 
6 

H 

a 
•A 

gg 

PS 

u  rt 

.2  S 
S^ 

c 

103 

P. 
P. 

P. 

P. 

P. 

P. 
P. 
P. 

P. 

i  R.U.8.     L.U.8. 
}  R.L.8. 

fR.U.8.7.6.5.3.2.1.        ] 
J  R.L.8.7.  3.2.1,              1 
1  L.L.1. 2.3.4.5.6.7. 8.       | 
[L.U.                    6.7.      J 
j  R.U.8.     L.U.8. 
I  R.L.8. 

R.U.7.     L.U.7 
R.L.321.     L.L.1. 23. 

R.U.8     L.L.5  7 

j  R.U.6.3.2.1.     L.U.3. 
}                         L.L.6.7. 
L.U.6.8.     L.L.5.7.8. 

jR.U.8.4.     L.U.4.5.      ) 
|R  L.7.5.     L.L.5.6.7.   J 

R.U.6.     R.L.6. 

l.E.S. 

2 
l.E.S. 

2 

l.E.S. 

2 

l.E.S. 

2 

1 

104 

1 

l.E.S. 
2 

l.E.S. 
2 

105 

l.E.S. 

2 

l.E.S. 
2 

1 

1 
1 
1 

l.E.S. 
2 

l.E.S. 

2 

1 

1 

1 

1 

1 

106 

107 

2 

108 
109 

1 

2 
2 

110 

1 

l.E.S. 
2 

1 

2 

111 

1 

1 

2 

Recokds 
upper    taw   in   oral   surgery 


221 


M 

c 

"3 

V 

> 

a 

C/2 

a 

u 

•5 

V 

RESULT 

REMARKS 

15 
10 
10 
15 
L5 

Bro.  gr.  X 
Bro.  gr.  X 
Bro.  gr.  X 
Bro.  gr.  X 
Bro.  gr.  X 

Perfect  Anaesthesia 

AND  LOWER  JAWS  IN  ORAL  SURGERY 


Inject.  L.  Jaw 

o 
en 

C    u 

<~ 
o 

H 

u 

o 
> 
o 
Z 

B 
O 

1  = 

o  c 
E-« 

So 

"rt 

a 
i) 
E 
H 

V 

> 

RESULT 

_  = 
~  E 

si 

c 
o 

c 

REMARKS 

B.N. 

1 
B.N. 

1 

6 

H 

H 

20 

Bro.  gr.  X 

Perfect  Anaesthesia 
ii                ti 

1 

11 

H 

04 

20 

Absolutely 
no 

reaction ! 



B.N. 
1 

6 

2 

2 

20 

l.E.S. 
2 

6 

2 

2 

2u 

B.N. 

1 

5 

5 

5 
8 

2 

2 
2 
2 

If 

2J 

20 

20 

20 
20 

4 

4 

4 

2 

H 

'J0 

222 


Local  Anaesthesia 

CONDUCTIVE  ANESTHESIA  IN 


OPERATION 


S-a 


112 

113 
114 
115 
116 
117 
118 
119 

120 
121 
122 
123 
124 
125 


126 
127 

128 


129 

130 
131 


Ground  down  Left  L.  4  and  7,   for  bridge  abut- 
ments 

Pulp  removed  Left  Lower  6  y.  molar    

Cavity  preparation  L.L.4.5.7 

Cervical  cavity  preparation  R.L.7.6 

Cavity  preparation  L.L. 6.7.8 

Cavity  preparation  L.L. 6  7 

Cavity  preparation  R.L.7.6 

Prepared  cavity  in  L.L.7.    Extracted  L.L.6 

Removed  pulp  R  L.  6 . .    

Cavity  preparation  L.  L.4 

Cavity  preparation  L  L.7 

Cavity  preparation  L.L  6.     Removed  pulp  L.L.4 

Prepared  L.L  4.7  for  bridge  abutments 

Cavity  preparation,  R.L.7  (very  sensitive) 


Prepared  compound  cavity,  R.L.7 

Prepared  very  sensitive  erosion  cavity,  L. L.7 

Removal  of  pulp,  L.L.7 

Removal  of  pulp,  R. L.6 

Cavity  preparation,  L.L.7 

Cavity  preparation,  R.L.6.7    


I1. 


2 
2 

2 
2 

2 

2 

2 
2 
2 


m 

ik 
m 

ik 

ik 

*k 

»K 

IK 

Ho 


IK 

IK 

*K 


IK 

IK 

IK 


IK 

2 
2 
2 
2 
2 
2 

2 

2 

iK 

2 
2 
3 


*  Records  furnished  by  S.  W.  A.  Frankan,  D.D.S.,  and  H.  F.  Barge,  D.D.S. 


Records 
mandible  in  operative  dentistry* 


223 


>     a 

o  c 

**-  u 

z  - 

o  " 

"S" 

E'5 

RESULT 

REMARKS 

c  c 

S£ 

<1 

4 

15    Perfect  Anaesthesia 

1 

8 

.. 

4 

12 

"                     " 

4 

5 

"                    " 

4 

10 

" 

4 
5 

9 

"                     " 

4 
5 

10 

c 

4 

5 

Child  aet.  XI,  very  nervous,  complained 
of  slight  pain 

4 

15 

"                     '' 

4 

1 
5 

12 
8 

.< 

4 
5 

10 

*'                     " 

* 

8 

"                     " 

Pallor  and  tremor,  passed  off 

2 
5 

10 

After  12  minutes  began  to  excavate 
cavity,  not  sensitive  any  more,  took 
wax  pattern  for  inlay 

4 

10 

"                    " 

4 
5 

12 

Patient  called  up  later  in  day  and  com- 
plained of  pain  in  temple 

4 

5 

Began  to  work  after  5  minutes,  entered 
pulp  chamber  after  15  minutes;  patient 
complained  of  slight  pain;  waited  a 
few  minutes,  placed  a  drop  of  novo- 
cain in  cavity  and  removed  a  very 
much  constricted  pulp 

J 

20 

Removed  pulp,  found  two  large  pulp 
nodules;  pressure  anaesthesia  had 
failed  previously 

* 

20 

No  sensation  after  18  min.,  prepared 
large  M.O.I  J.  cavity 

I 

10 

Prepared  2  compound  cavities,  took 
1  hour 

224 


Local  Anaesthesia 

conductive  anaesthesia  in 


u 

V 

E 

3 

•A 

V 

n 
O 

OPERATION 

o 

3 

H 

Ph' 

Ph' 
< 

a 

s 

« 
o 
fa 

"a 
13 

o 
rt 

c 
.2 

<2 

c 

.5 
"« 

u 

o 
>■ 
o 

■ss. 

182 

Cavity  preparation  R.U.7.6 
Pulp  removal  L.U.3 

Cavity  preparation  L.U.6 

Pulp  removal  L.U.6 

Preparation  of  root  for 
Logan  Crown  L.U.I. 

Preparation  of  bridge  abut- 
ments R.U.7.3 

Cavity  preparation  L.U.6.8 

Preparation  for  crown  L  U.6 
Cavity  preparation  R.U.7.6 
f  Cavity    preparation   R. "] 
I      U.7.6                                I 
J  Pulp  removal  L.U.7         [ 
[     at  one  session               J 
j  Pulp  removal  R.U.6.      \ 
\      Cavity  prep.    L.U.6. 7  \ 
Cavity  prep.  L.U.I. 2.    Pulp 

removal  L.V.3 
Cavity  preparation  L.U.8 
Cavity  preparation  L.U.6 
Cavity  preparation  L.U.I 
Pulp  removal  R.U.I 
Cavity  preparation  R.U.7 

Pulp  removal  R.U.I* 
Pulp  removal  R.U.5* 

IK 

IK 
IK 
IK 

138 

2  inj. 
•K   Ea- 

184 

IK 

IK 

185 

% 

IK 
IK 

IK 

IK 

iK 
IK 

iK 

136 

K 

IK 
1 

A 

few 

drops 

137 
138 

IK 

IK 

IK 

2 

1KR- 

1KL- 
li^E.S. 

139 

140 

141 

149, 

iK 

iK 
iK 
iK 
iK 
iK 
iK 

IK 
iK 

143 

IK 

144 

IK 
IK 

145 

H 

146 

iK 
IK 

147 

148 

iK 

149 

IK 

2 

150 

*  Are  Infiltration  Anaesthesias. 


Records 

UPPER  JAW  IN  OPERATIVE  DENTISTRY 


225 


"3 

°^ 

us 

e 

"o 

=  = 

2£ 

X) 

3'- 

V 

c 

2   S 

£ 

m 

3 
0 

jH 

RESULT 

w 

REMARKS 

g 

«:  3 

O 

< 

_  o 
3  i 

V 

2 

o 

-  o 

< 

H 

IK 

1 
s 

6 

Perfect  Anaesthesia 

None 

3 

2 
s 

10 

" 

" 

IK 

1 
s 

7 

.< 

" 

2 

i. 

9 

S 

Good 

Patient    complained  of  a 
very  slight  pain 

2X 

5 

a 

8 

Perfect  Anaesthesia 

Infiltrated  gum  about  Cen- 
tral with  a  few  drops 

»K 

10 

■  1              11 

" 

IK 

1 
s" 

8 

Good 

Patient    complained   of  a 
little  pain 

IK 

1 

7 

Perfect  Anaesthesia 

" 

2 

4 

V 

6 

11               11 

" 

3 

2 
s 

8 

l  R.U.6.  Slight  Sensation. 

-       L  U.6.7.  Perfect Anaas- 

(      thesia 

3 

a 

5 

Perfect  Anaesthesia 

" 

j  Slight    cyanosis,    disap- 
(      peared  shortly. 

IK 

i 

5 

ii              <• 

" 

IK 

* 

8 

11              ii 

" 

2 

4 
9" 

8 

11              ii 

" 

IK 

* 

7 

11              11 

" 

IK 

£ 

10 

11              11 

" 

2 

1 

5 

f  Injected  %  ccm.  between 
neck  and  apex  facially 

IK 

J 

5 

\  Injected  1  ccm.  between 
neck  and  apex  on   pal- 
1  atine  aspect 

f  Injected  1  ccm.  on  Lin- 

2 

J 

8 

•  <              ii 

,, 

j  gual  surface 

j  Injected  1  ccm.  on  Buccal 

(.aspect 

226  Local  Anesthesia 

Reviewing  the  preceding  tables,  we  have  a  total 
of  one  hundred  and  fifty  conductive  anaesthesias, 
of  which  seventy  are  in  the  lower  jaw,  for  oral 
surgical  cases,  with  fifty-nine  perfect  anaesthesias ; 
of  these  fifty-nine,  three  had  to  be  injected  twice. 
Case  No.  2  complained  of  a  little  pain.  Cases  Nos. 
7,  17,  18,  20,  22,  28,  33  were  children,  who  were  all 
more  or  less  frightened.  It  is  difficult  to  say 
whether  these  children  cried  from  fright  or  pain, 
particularly  as  some  of  these  cases  did  not  wince 
when  the  gum  and  lips  were  pricked  with  a  pin. 
The  writer  once  gave  a  mandibular  injection  to  a 
child  three  years  old  for  the  removal  of  an  ab- 
scessed molar;  the  youngster  cried  very  bitterly, 
but  stated  that  he  felt  no  pain,  but  was  frightened. 

Case  No.  46  was  injected  five  times,  and  no  an- 
aesthesia of  the  mandibular  nerve  was  obtained. 
Failure  in  this  case  was  due  to  anatomical  anom- 
aly of  the  mandible. 

Cases  Nos.  2-24  gave  evidence  of  only  part- 
anaesthesia. 

The  thirty-two  conductive  anaesthesias  in  the  up- 
per jaw  in  oral  surgical  cases  were  all  perfect. 

The  nine  conductive  anaesthesias  in  both  upper 
and  lower  jaws  were  all  perfect. 

The  forty  anaesthesias  in  operative  dentistry 
cases  were  all  (excepting  Cases  Nos.  119,  135, 
138)  perfect. 

Summing  up  the   experience  of  more  than  a 


Unpleasant  Effects  227 

thousand  conductive  anesthesias,  the  writer  would 
say  that  failure  to  obtain  perfect  results  is  due  to : 

1.  Faulty  technique,  i.e.,  not  injecting  at  the 
proper  place. 

2.  Personal  equation  of  the  patient  (idiosyn- 
crasy). 

3.  Not  waiting  sufficiently  long. 

Unpleasant  After-Affects 
(  faulty  asepsis, 

1.  Pain  due  to  1  the   use   of  hetero-tonic   solu- 

(      tions. 

«    «      i-..       -,      L    [  faulty  asepsis, 

2.  Swelling  due  to  j  musele  infiltration. 

„   ,     .     ,  .        -,  ( muscle  infiltration, 

3.  Locked  jaw  due  to  j  infection  (faulty  asepsis). 

4.  Palpitation,  blanching,  due  to  overdose  of 
adrenalin. 

Sometimes  a  mandibular  injection  will  give  the 
symptoms  of  a  perfect  anaesthesia,  but  when  cer- 
tain parts  of  the  tooth  are  reached,  the  dento- 
enamel  line  or  the  pulp,  sensation  is  still  found. 
This,  the  writer  believes,  is  due  to  the  fact  that  the 
anaesthetic  has  not  been  absorbed  by  the  nerve 
through  its  entire  thickness,  and  that  those  fibres 
reaching  the  sensitive  part  have  not  become  infil- 
trated by  the  anaesthetic. 

The  basal  requisites  for  successful  local  anaes- 
thesia in  all  its  forms  are : 


228  Local  Anesthesia 

1.  Absolute  asepsis. 

2.  The  use  of  isotonic  solutions. 

3.  Knowledge  of  anatomical  landmarks. 

4.  Judgment  of  patient's  physical  state. 

5.  The  use  of  pure,  non-oxidized  drugs;  a  dis- 
colored tablet  or  solution  should  not  be  used. 

Any  ill  effects  following  the  use  of  novocain- 
suprarenin,  as  blanching,  cyanosis,  perspiration, 
dyspnoea  or  palpitation,  are  counteracted  by  the 
inhalation  of  amyl-nitrite  or  vaporole  or  the  ad- 
ministration of  coffee.  The  writer  never  had  oc- 
casion to  employ  more  heroic  treatment. 

Key  to  Conductive  Anaesthesia  fob  Exteactions 
Upper  Jaw 

3d  Molar,  Tuberosity,  1  ccm. ;  P.P.C.,  1  ccm. 
Wait  5-10  minutes. 

2d  Molar,  Tuberosity,  1  ccm.;  P.P.C.,  1  ccm. 
Wait  5-10  minutes. 

1st  Molar,  Tuberosity,  1  ccm.;  P.P.C.,  1  ccm. 
Wait  5-10  minutes. 

2d  Bicuspid,  Tuberosity,  1  ccm. ;  P.P.C.,  1  ccm. 
Wait  5-10  minutes. 

1st  Bicuspid,  Infraorbi.  for.,  1  ccm. ;  A.P.C.,  y2 
ccm.    Wait  5-10  minutes. 

Canine,  Infraorbi.  for.,  1  ccm. ;  A.  P.  C,  y2  ccm. 
Wait  5-10  minutes. 


Keys  229 

Lateral,  Infraorbi.  for.,  1  ccm. ;  A.P.C.,  y2  ccm. 
Wait  5-10  minutes. 

Central,  Infraorbi.  for.,  1  ccm. ;  A.P.C.,  y2  ccm. 
Wait  5-10  minutes. 

Lower  Jaw 

3d  Molar,  Mandibular,  2  ccm.  Wait  10-20 
minutes. 

2d  Molar,  Mandibular,  2  ccm.  Wait  10-20 
minutes. 

1st  Molar,  Mandibular,  2  ccm.  Wait  10-20 
minutes. 

2d  Bicuspid,  Mandibular,  or  Mental  for.,  1  ccm. ; 
and  Lingual  Aspect  of  Bic.,  y2  ccm. 

1st  Bicuspid,  Mandibular,  or  Mental  for.,  1  ccm. ; 
and  Lingual  Aspect  of  Bic,  y2  ccm. 

( lanine,  Mental  for.,  1  ccm. ;  Mental  fossa  of  op- 
posite side,  !/2  ccm- 

Lateral,  Mental  for.,  1  ccm. ;  Mental  fossa  of  op- 
posite side,  y2  ccm. 

Central,  Mental  for.,  1  ccm. ;  Mental  fossa  of  op- 
posite side,  y2  ccm. 

Also  Lingual  Aspect  of  Canine,  y2  ccm.;  of 
Lateral,  y2  ccm. ;  of  Central,  y2  ccm. 

Waiting  for  Lower  2d  Bicuspid,  Central,  5-10 
minutes. 

A  Mandibular  injection  can  be  done  for  all  lower 
teeth  ;  waiting  time  is  then  10-20  minutes. 


230  Local  Anaesthesia 

Key  to  Conductive  Anaesthesia  for  Multiple 

Extractions 

To  Anaesthetize  One-Half  Upper  Jaw. 
Tuberosity,  1  ccm. 
P.P.C.,  1  ccm. 
A.P.C.,  i/2  ccm. 
Infraorb.  for.,  1  ccm. 

To  Anaesthetize  the  Upper  Jaw  Completely 
Tuberosity,  1  ccm.,  on  both  sides. 
P.P.C.,  1  ccm.,  on  both  sides. 
A.P.C.,  1  ccm.,  on  both  sides. 
Infraorb.  for.,  1  ccm.,  on  both  sides. 

To  Anaesthetize  the  Whole  Left  Side,  and  the 

Right  Up  to  and  Including  the  Canine 
Mandibular,  2  ccm  (left). 
Mental  for.,  1  ccm.,  on  other  side  (right). 
Lingual  Aspect  of  right  side  in  anterior  por- 
tion, 1  ccm. 

To  Anaesthetize  Six  Anterior  Teeth  in  Mandible 
Mental  for.,  1  ccm.,  on  both  sides. 
Lingual  Aspect,  y»  ccm. 

To  Anaesthetize  the  Six  Anterior  Teeth,  Upper 

Jaw 

Infraorbital  for.,  1  ccm,  on  both  sides. 
A.P.C.,  1  ccm. 


Keys  231 

To  Anaesthetize  Four  Lower  Centrals 
Mental  fossa,  on  both  sides,  1  ccm. 
Incisal  foramina,  y2  ccm. 

Key  to  Infiltration  Anaesthesia  for  Extractions 
Upper  Jaw 

3d  Molar,  inject  facially  about  center  of  root, 
\y2  ccm. ;  lingually,  y2  ccm. 

2d  Molar,  inject  facially  about  center  of  root, 
iy2  ccm. ;  lingually,  y2  ccm. 

1st  Molar,  inject  facially  about  center  of  root, 
iy2  ccm. ;  lingually,  y2  ccm. 

2d  Bicuspid,  inject  facially  about  center  of  root, 
1  ccm. ;  lingually,  y2  ccm. 

1st  Bicuspid,  inject  facially  about  center  of  root, 
1  ccm. ;  lingually,  y2  ccm. 

Canine,  inject  facially  about  center  of  root,  1 
ccm. ;  lingually,  y2  ccm. 

Lateral,  inject  facially  about  center  of  root,  y2 
ccm. ;  lingually,  y2  ccm. 

Central,  inject  facially  about  center  of  root,  y2 
ccm. ;  lingually,  y2  ccm. 

Lower  Jaw 

3d  Molar,  inject  facially  about  center  of  root, 
V/2  ccm. ;  lingually,  y2  ccm. 

2d  Molar,  inject  facially  about  center  of  root, 
iy2  ccm. ;  lingually,  y2  ccm. 


232  Local  Anaesthesia 

1st  Molar,  inject  facially  about  center  of  root, 
iy2  ccm. ;  lingually,  y2  ccm. 

2d  Bicuspid,  inject  facially  about  center  of  root, 
1  ccm. ;  lingually,  y2  ccm. 

1st  Bicuspid,  inject  facially  about  center  of  root, 
1  ccm. ;  lingually,  V2  ccm. 

Canine,  inject  facially  about  center  of  root, 
1  ccm. ;  lingually,  y2  ccm. 

Lateral,  inject  facially  about  center  of  root, 
y2  ccm. ;  lingually,  y2  ccm. 

Central,  inject  facially  about  center  of  root, 
y2  ccm. ;  lingually,  y2  ccm. 

Key  to  Local  Anaesthesia  in  Operative  Dentis- 
try.    For  Operations  upon  : 

Upper  Molars — Tuberosity — iy2  ccm.  wait  5-10 
minutes. 

Upper  Bicuspids — Infiltrate  both  Facial  and  Lin- 
gual aspect  of  process  near  apex — y2-l  ccm. 
wait  5-10  minutes. 

Upper  Canine — Infraorbital  foramen  1  ccm.  wait 
5-10  minutes. 

]  as  Canine  or  Infiltrate  as  Bicus- 

Upper  .Lateral  [  ^^  Qr  inser^  tampons  dipped  in 

Upper  Central  j  20^o  Novocain  soL  into  narce> 

Lower  Molars — Mandibular  injection  2  ccm.  wait 
10-20  minutes. 


Conclusions 


233 


Lower    Bicus-  ]  Mental    foramen 

pids  fl  ccm.  wait  5-10, 

Lower  Canine  )  minutes. 

T  T  ,  )  Infiltrate  mental 

Lower  Lateral     c         .,  -, 

r  „  .  y  fossa  1  ccm.  wait 

Lower  Central     c  -.  A      •      , 

}  5-10  minutes. 


or  mandibular 
injection  2 
ccm.  (and 
mental  fora- 
men or  men- 
tal fossa  on 
opposite 
side  for  cen- 
tral region). 

The  injection  of  the  incisal  fossae  on  both  sides 
as  well  as  lingual  infiltration  will  anaesthetize  the 
four  incisors. 

The  author  has  attempted  to  present  the  subject 
of  Local  Ana?sthesia,  as  of  interest  to  the  Dental 
and  Oral  Specialist  in  as  concise  and  practical 
form  as  possible. 

This  book  should  not  be  looked  upon  as  a  Text- 
book, but  as  a  guide  to  the  student  and  practi- 
tioner. In  conclusion  the  writer  desires  to  reiter- 
ate that  Local  Anaesthesia  in  its  various  forms 
is  the  staunchest  ally  of  the  Oral  specialist  in 
combating  pain,  but  that  in  its  thoughtless  and  in- 
correct use  lurks  danger. 

It  is  not  a  method  to  be  employed  for  scaling 
teeth  or  to  gratify  the  whim  of  a  patient,  but  it 
is  a  means  of  reducing  pain. 

All  types  of  Anaesthesia  must  be  administered 
with  caution,  whether  Local  or  General. 


234  Local  Anaesthesia 

It  is  foolhardy  to  use  without  proper  instruc- 
tion. 

It  is  dangerous  in  the  hands  of  the  man  who 
does  not  appreciate  the  full  meaning  of  Asepsis. 


XII 

Useful  Formulae  and  Prescriptions 

1.  Formulae 

Thiersch's  Solution 

Used  as  a  wet  dressing  in  inflammation  and 
swelling  of  soft  parts ;  also  for  irrigation  of  sup- 
purating wounds. 

Acidi  Salicylici 2.0  o  ss 

Acidi  Borici  12.0  3  iii 

Aquse  dest 1000.0  I 

S.  For  external  use. 

Ringer's  Solution 
Used  as  a  solvent  medium  for  local  anaesthetics. 

Natrii.  chloridi 0.5 

Calcii  chloridi 0.004 

Kalii.  chloridi 0.02 

Aquae  dest 100.0 

Normal  Salt  Solution 
A  0.6-0.9  %  solution  of  natrium  chlorid  in  sterile 
water,  solvent  agent  for  local  anaesthetics — me- 
dium for  intravenous  or  hypodermic  injections. 
Irrigating  maxillary  sinus. 

235 


236  Local  Anesthesia 

Permanganate  of  Potash  Solution 

Kalii  hypermangan 1.0 

Aquae  dest 100 . 0 

Fifteen  to  twenty  drops  in  one-half  glass  of 
water,  a  good  deodorant  wash.  If  used  any  length 
of  time,  teeth  and  tongue  discolor.  Can  be  used 
for  irrigating  suppurating  wounds,  cyst  cavities, 
necrotic  areas,  maxillary  sinus.  Not  to  be  used 
stronger. 

Liquor  Alumini  Acetatis 

Alumini  sulphatis    300.0 

Acidi  acetici aa  300 . 0 

Calcii  carbonici 130 . 0 

Aquae  dest 1000.0 

Diluted  with  four  or  ten  parts  of  water,  well 
cooled,  very  useful  as  an  external  application  in 
swelling. 

Diluted  with  nine  or  ten  parts  of  water,  a  good 
astringent  mouth  wash.  Not  to  be  used  for  any 
length  of  time  as  a  wash,  as  the  teeth  become  dis- 
colored; the  discoloration,  however,  is  easily  re- 
moved with  pumice. 

Liquor  Burowi  acts  like  the  above ;  it  is  not  offi- 
cial in  this  country. 

ty  2.  Prescriptions 

Liq.  Alumini  Acetatis,  U.S.P.,  120.0  (g  iv) 
S.  Dilute  with  four  parts  of  water  and  apply  ex- 


Prescriptions  237 

ternally  for  one  hour,  three  times  a  day.    Label 
for  external  use. 

„  As  a  wash 

Liq.  Alumini  Acetatis,  U.S.P.,  120.0  (5  iv) 
S.  Two  teaspoonfuls  in  a  half-glass  of  water  as 

mouth  wash.    Label  for  external  use. 

Not  to  be  used  before  meals,  as  it  might  affect 

the  appetite. 

_  Antiseptic  Washes 

l> 

Sol.  Kalii  hypermang.,  1%,  60.0  (3  ii) 

S.     Fifteen  drops  in  one-half  glass  of  water  as 

mouth  wash. 

B 

Sol.  Hydrogenii  hyperoxyd,  3%,  120.0  (B  iv) 
S.     One  tablespoonful  in  one-half  glass  of  water 

as  mouth  wash. 

Not  to  be  used  for  any  length  of  time,  as  the 

teeth  become  discolored,  the  tongue  coated,  and  it 

produces  a  pasty  taste. 

Liq.  Antisepticus  Alkal.,  U.S.P.,  120.0  (5  iv) 
S.     A  tablespoonful  in   a  glass   of   water   as 

mouth  wash. 

If  Chlorate  of  Potash  is  required,  the  following 

wash  is  useful : 


238  Local  Anaesthesia 

Kalii  chloras 4.5  3  iss 

Tr.  Myrrhae 30.0  §  i 

Aquae  dest.,  q.s.ad 90.0  §  iii 

M.  S.     A  teaspoonful  in  one-half  glass  of  water 
as  mouth  wash. 

t.  Miller's  Wash 

Thymolis   0 .  25  gr.  iiiss 

Acidi  Benzoici 3.0     gr.  xlv 

Tr.  Eucalypti 15 . 0    §  ss 

Alcoholis  absol 100.0    §  iiiss 

01.  Menthae  pip 1.0     m  xv 

S.  A  teaspoonful  in  a  glass  of  water  as  mouth 
wash,  after  meals  and  before  retiring. 

t>  Astringent  Washes 

Liquor  Burrowi,  or  Liq.  Alumini  Acetatis, 

U.S.P.,  120.0  (3  iv) 
S.     One  to  two  teaspoonfuls  in  one-half  glass  of 
water  as  mouth  wash. 

Spt.  Menthae  pip 4.0        oi 

Acidi  Tannici 0 . 3-0 . 6  gr.  v-gr.  x 

Tr.  Myrrhae 15.0        %  ss 

Tr.  Arnicae,  q.s.ad. .  .120.0        S  iv 

M.  S.    A  teaspoonful  in  one-half  glass  of  water 


Prescriptions  239 

as  mouth  wash,  three  times  daily.     Label  shake 
well.    (Not  to  be  used  directly  before  eating.) 

Zinci  Sulphatis. .  .0.5-2.0  gr.  vii-gr.  xxx 
Aquae  Rosaa 120.0  3  iv 

S.    (Astringent  stimulating  wash)  Mouth  wash. 
For  Acute  Periostitis  or  Attends 

Unguenti  Ichthyoli,  5-20  %. . .  .60.0  I  ii 
S.     Apply  locally. 

Internal  Medication 
Nerve  Sedatives 

Tab.  Bromural  (Knoll  &  Co.),  aa  0.3  (gr.  v) 

D.  No.  x. 

S.  One  to  two  tablets  twenty  minutes  before 
operation. 

If  to  be  given  for  continued  action,  give  one  to 
two  tablets  three  times  daily. 

Bromural  is  a  very  happy  combination  of  Bro- 
mides and  Valerian. 

Kalii  bromid 30.0  3  i 

Aqua1  Cinnamonis 120.0  f,  iv 

•S.    A  teaspoonful  in  a  little  water. 


240  Local  Anesthesia 

For  Post  Extractive  Pain 

Caps.  Trigemin  aa 0.3  gr.  v 

D.    No.    vi. 

S.    One  capsule  every  three  hours  until  relieved, 

Phenacetine 

Aspirine,  aa 2.0  gr.  xxx 

Divide  in  chartulas  No.  vi. 

S.    One  powder  every  three  hours  until  relieved. 

If  an  opiate  is  required : 

Phenacetine 0.7     gr.  xii 

Natrii  bicarb 1.3     gr.  xx 

Codeine  Sulph 0 .  06  gr.  i 

Caffeine  citrat 0 .  24  gr.  iv 

Misce  et,  divide  in  chartulas  No.  iv. 

S.    One  powder  every  three  hours  until  relieved. 

In  extreme  cases,  where  the  patient  is  suffering 
severe  pain  and  is  very  restless  : 

Morphias  Sulph 0 .  015  gr.  y^ 

Kalii  Bromid 2.0       gr.  xxx 

Aquae 30 . 0       o  i 

S.    One-half  to  be  taken  at  once ;  balance  in 
three  hours,  if  necessary. 
Non-repitantur ! 


Prescriptions  241 


Laxatives 


It  is  always  advisable  to  prescribe  a  laxative  in 
cases  of  alveolar  abscess. 

Castor  oil  (01.  Eicini)  is  one  of  the  ideal  drugs, 
but  its  unpleasant  taste  makes  it  difficult  to  ad- 
minister. It  can  be  given  in  gelatin  capsules. 
which  renders  it  tasteless  and  odorless.  These 
capsules  are  made  up  in  different  sizes ;  for  adults 
six  21/2  gram  capsules  (6  X  37.5  =  225  minims, 
about  a  half  ounce)  constitute  the  usual  dose. 
These  capsules  are  swallowed  easier  if  they  are 
moistened  in  water.  They  are  best  taken  before 
retiring. 

Cascara  Sagrada  can  be  prescribed  in  liquid  or 
solid  form. 

Tab.  Cascara  Sagrada,  aa  0.3 ;  chocolate  coated. 

One  to  two  tablets  before  retiring. 

Or— 

Ext.  Cascara  Sagrada  Ad.,  10-30  minims. 


3 


V 


Liq.  Magnesii  Citratis,  U.S.P. 
S.    One-half  to  one.    Twelve-ounce  bottle. 

For  the  Control  of  Hemorrhage 

Vin.  ergotac  (Squibb's) . .  .90.0  5  iii 
S.    A  teaspoonful  every  two  hours. 


242  Local  Anaesthesia 

Acidi  Gallici 4.0  3  i 

Acidi  Sulphurici  diluti ....   8.0  3  ii 

Aquas  dest.,  q.s.ad 90.0  %  iii 

S.    A  teaspoonful  every  four  hours. 


K 


9 


Calcii  lactatis 6.0  5  iss 

Divide  in  chartulas  No.  vi. 

S.    One  powder  every  three  hours. 

General  Tonic 

Strychniae  Sulphatis 

Acidi  Arsenoisi aa  0 .  06 

Quininae  Sulphatis 2.0 

Ferri  Sulphatis  Axsiccat 1.0 

M.  et.  f.  piluae  No.  xxx. 
S.    One  after  each  meal. 


XIII 

Poisons  and  Their  Antidotes 
Aconite 

Antidote:  Keep  patient  in  prone  position,  feet 
higher  than  head.  Place  hot  bottles  about  body  to 
retain  bodily  heat.  Ether  hypodermatically ;  this 
followed  by  alcohol,  and  this  by  digitalis.  If 
breathing  fails,  artificial  respiration;  if  the  heart 
fails,  a  few  drops  only  of  amyl  nitrite  by  inhala- 
tion. 

Ammonia 

Milk,  vinegar,  dilute  citric  acid;  small  pieces  of 
ice. 

Arsenic 

Stomach-pump,  external  heat,  stimulants  and 
chemical  antidote,  hydrated  sesquichloride  of  iron 
and  magnesia.  Give  morphine  to  allay  pain ;  large 
draughts  of  water  to  flush  kidneys  and  dilute 
poison. 

Carbolic  Acid 

Large  doses  of  whiskey;  Epsom  salts,  warm 
mucilaginous  drinks,  hot  applications  to  extremi- 
ties, ('luetics;  stomach-pump  with  great  care,  as 
tie-  intestinal  tract,  mouth  and  pharynx  is  cau- 
terized. 

243 


244  Local  Anaesthesia 

Cocaine 
Ammonia,  coffee,  strychnia,  ether  and  alcohol. 
If    convulsive    in    type,    treat    like    strychnine 
poisoning. 

Corrosive  Sublimate 
Large  amounts   of  egg  albumen,  followed  by 
stomach-pump,  external  heat,  stimulants. 

Ether 
Artificial  respiration;  strychnine  hypodermat- 
ically,  full  dose ;  friction  and  hot  applications ; 
dash  ether  on  chest.    Laborde's  method  of  trac- 
tion of  tongue. 

Iodine 
Large    amounts    of    starch,    hot    applications, 
emetics  or  stomach-pump;  hypodermic  injection 
of  alcohol,  ammonia,  atropine,  digitalis. 

Iodoform 
Sodium  bicarbonate  to  combine  with  iodine,  al- 
cohol, diuretics  and  hot  blankets. 

Mineral  Acids 
Magnesium,  lime,  soap,  white  of  egg  as  anti- 
dotes ;  white  of  egg,  external  heat,  oils  and  opium 
to  relieve  irritation. 

Mercury  Bichloride 
See  Corrosive  Sublimate. 


Antidotes  245 

Morphine 
Emetics  or  stomach-pump,  tannic  acid,  black 
coffee,  electricity  and  other  measures  to  keep  pa- 
tient awake;  walk  him  around;  atropine  or  strych- 
nine hypodermatically  if  respiration  fails,  artifi- 
cial respiration;  repeated  washing  of  stomach. 
Permanganate  of  potash. 

Novocain 
Amyl  nitrite  inhalation,  coffee  (see  Cocaine). 

Nitrate  of  Silver 
Common  salt  as  antidote;  opium  and  oils  to 
allay  irritation,  also  large  amounts  of  milk  and 
soap  and  water ;  maintain  bodily  heat. 

Potassium  Chlorate 
Diuretics,  saline  infusion. 

Strychnine 

Inhalation  of  amyl  nitrite,  stomach  pump,  tan- 
nic acid,  followed  by  physiologic  antidotes,  potas- 
sium bromide,  gr.  lx,  and  choral,  gr.  xx.  If  con- 
vulsions prevent  swallowing,  chloroform  patient 
carefully,  and  antidotes,  per  rectum,  in  starch 
water.  Amyl  nitrate  hypodermatically  if  relaxa- 
tion docs  not  occur. 

To  produce  emesis  promptly  administer  apo- 
morphine,  gr.  1/10;  gr.  1/5  hypodermatically. 


XIV 

Treatment  of  Emergencies 

Fainting, 

due  to  cardiac  depression,  causing  cerebral 
anaemia.  Lay  patient  flat,  head  lower  than  feet; 
loosen  all  tight  clothing  and  admit  fresh  air.  Give : 
Aromatic  ammonia  ("Vaporole,"  Burroughs, 
Wellcome  &  Co.)  by  inhalation,  breaking  a  cap- 
sule in  towel.  Whiskey  diluted  in  water.  Aro- 
matic spirits  of  ammonia  2.0,  or  xxx  drops  diluted 
in  water. 

Hiccoughs 

Spirits  of  camphor  one  drachm.  Hoffman's 
anodyne  one  drachm  in  water.  Amyl  nitrite  by  in- 
halation. 

Heartfailure 

Adrenalin  1 :  1000,  one  to  two  drachms  in  pint 
of  normal  saline,  intravenously  or  by  hypoder- 
modysis. 

Epistaxis 

Pack  nostril  tightly  with  gauze  dipped  in  ad- 
renalin (adrenalin  1:1000,  1  drachm  to  6  oz.  of 
water),  and  press  the  alae  of  the  nose  together  with 
the  fingers. 

246 


Emergencies  247 

Collapse  or  Shock 

This  may  be  mild  or  severe ;  the  mild  form  will 
show  in  blanching  and  a  few  gasping  respiratory 
movements,  and  then  color  will  return  to  the  face 
and  the  patient  will  feel  better.  Laying  the  pa- 
tient flat,  and  aromatic  ammonia  by  inhalation, 
will  usually  overcome  this. 

The  more  severe  form  will  be  indicated  by 
blanching,  clammy  skin,  beads  of  perspiration  on 
the  forehead,  dilated  pupils,  diminished  reflexes, 
frequent  irregular  pulse  and  feeble  sighing  respi- 
ration. Temperature  subnormal,  the  patient  may 
be  unconscious  or  retain  his  senses. 

Treatment:  Patient  should  be  laid  flat,  head 
low,  covered  with  blankets,  dry  heat  to  body.  If 
he  can  swallow  whiskey  in  small  doses,  1  drachm, 
with  y2  drachm  spirits  of  ammonia,  or  strychnia 
in  gr.  1/30  gr.  1/20  hypodermatically,  or  caffeine 
in  gr.  ii  doses,  or  ether  30  min.  hypodermatically. 

Hysterical  Attack 
Application  of  cold  water  to  the  face,  ammonia 
by  inhalation,  or  Hoffman's  anodyne,  30  drops  in 
water.  If  convulsions  occur,  ice  to  the  back  or 
apomorphine,  gr.  1/12,  hypodermatically;  this  will 
cause  emesis  and  stop  the  attack. 

Nervous  Attack 
Bromides,  Valerian  Bromural  (Knoll),  gr.  x. 


248  Local  Anesthesia 

Convulsions 
Place  Denhart  gag  between  patient's  jaws,  so 
he  cannot  close  his  teeth  and  bite  his  tongue. 
Keep  a  pair  of  tongue  forceps  handy,  so  that  the 
tongue  can  be  grasped,  that  it  cannot  be  swal- 
lowed. Lime  chloral  and  bromides ;  if  violent,  a 
little  chloroform  by  inhalation. 


XV 

Glossary 

Abscess,  a  localized  collection  of  pus  surrounded 
by  a  lymph  wall. 

Aconite,  a  genus  of  herbs ;  also  the  poisonous  roots 
and  leaves  of  aconitum  napellus. 

Acute,  rapid,  severe,  sharp. 

Adrenalin,  the  active  principle  of  the  suprarenal 
gland. 

Alkaloid,  an  organic  base  of  vegetable  origin  caus- 
ing toxic  effects. 

Alum,  sulphate  of  potassium  and  aluminum. 

Alveolus,  bony  socket  of  a  tooth. 

Alveolar  process,   portions   of  jaw   bearing   the 
teeth. 

Alveolitis,  inflammation  of  alveolus. 

Ammonia,  a  pungent  gas,  NH3,  very  soluble  in 
water. 

Analgesia,  insensibility  to  pain. 

Anaemia,  a  deficiency  of  blood  or  red  blood  cor- 
puscles ; 
primary,  that  caused  by  disease  of  the  blood  or 

the  blood-making  organs; 
secondary,  that  due  to  a  distinct  cause,  or  loss  of 
blood. 

249 


250  Local  Anaesthesia 

Anaesthesia,  a  state  of  insensibility ; 
general,  one  affecting  the  whole  body ; 
local,  limited  to  a  part  of  the  body ; 
conductive,    due    to   blocking    off    an   afferent 

nerve ; 
regional,  limited  to  a  part  supplied  by  an  af- 
ferent nerve  which  has  been  anaesthetized; 
infiltration,  due  to  subcutaneous  injections. 
Angina,  a  sense  of  suffocation ; 

Vincent's,  a  diphtheroid  inflammation  due  to  a 

spirillum  and  fusiform  bacillus ; 
Ludwig's,  cellulitis  of  submental  and  sub-maxil- 
lary tissues. 
Antrum,  a  cavity,  especially  in  bone ; 

of  Highmore,  cavity  in  the  superior  maxilla. 
Anuria,  suppression  of  urine. 
Arsenic,  a  chemic  element;  in  small  doses  its  com- 
binations useful  as  a  tonic;  also  used  as  an 
escharotic. 
Asepsis,  an  absence  of  septic  matter. 
Aspirin,  aceto   salicylic  acid;   an  anti-rheumatic 

remedy ;  useful  to  stop  all  types  of  pain. 
Asthma,  paroxysmal  dyspnoea,  with  oppression. 
Astringent,  an  agent  producing  contraction  of  or- 
ganic tissue  or  the  arrest  of  discharges. 

Blanching,  turning  pale. 

Bromural,  proprietary  combination  of  Bromide 
and  Valerian. 


Glossary  251 

Calomel  ointment,  an  ointment  containing  calomel. 
Capsula,  a  capsule. 

Chancre,  primary  or  hard  syphilitic  nicer,  the  ini- 
tial lesion. 
Chartula,  a  paper  containing  a  medicine. 
Chronic,  long  continued,  the  reverse  of  acute. 
Clot,  a  mass  of  thickened  blood,  coagulum. 
Clotting,  the  thickening  of  drawn  blood. 
Coaguability,  the  ability  to  clot. 
Curetage,  the  use  of  a  curette  (scraping). 
Cyst,  a  membranous  sac  containing  liquid. 
Cystic,  pertaining  to  a  cyst ; 
degeneration,  degenerating  with  cyst  formation. 

D.,  abbreviation  for  donne  (latin),  give. 
Degeneration,    deterioration    of   a    structure    or 

organ. 
Diabetes,  a  disease  of  nutrition. 
Disintegration,  destruction. 
Divide,  divide. 
Divide  in,  divide  into. 
Drainage,  the  gradual  removal  of  contents  from  a 

suppurating  cavity. 

Edema,    an   accumulation    of    serum    in   cellular 

tissue. 
Embolism,  obstruction  of  a  blood  vessel  by  an 

embolus. 
Embolus,  a  blood  clot  or  other  body  carried  by  the 

blood. 


252  Local  Anesthesia 

Endocarditis,  inflammation  of  endo-cardium,  the 
inner  lining  of  the  heart. 

Endosmosis,  the  passage  of  a  liquid  through  a 
septum  from  without  inward. 

Ergot,  a  fungus  parasitic  upon  rye  (Claviceps 
purpura). 

Erotic,  pertaining  to  sexual  passion. 

Etiology,  the  science  of  the  causes  of  diseases. 

Exosmosis,  the  passage  of  a  liquid  through  a  sep- 
tum from  within  outward. 

Fever,  disturbed  nutrition,  associated  with  rise  of 

body  temperature. 
Fever  sore,  ulcer  supposedly  to  be  caused  by  fever. 

Gallic  acid,  acid  obtained  from  nutgalls. 

Gangrene,  death  of  soft  tissue. 

Grain,  the  smallest  division  of  a  pound,  1/480  of 

an  ounce. 
Gram,  unit  of  weight  of  metric  system,  equals 

15.43  grains,  troy  weight. 

Hemoglobin,  coloring  matter  of  red  blood  cor- 
puscles. 

Hemoglobinometer,  an  instrument  to  determine 
the  amount  of  hemoglobin  in  the  blood. 

Hemophilia,  a  disease  of  the  blood  prohibiting  its 
normal  coagulation. 

Hemophiliac,  one  who  suffers  from  hemophilia. 


Glossary  253 

Hemorrhage,  escape  of  blood  from  a  vessel  artery, 
vein  or  capillary ; 
primary,  loss  of  blood  at  time  of  injury ; 
secondary,  loss  of  blood  after  bleeding  has  once 
stopped. 

Hypertonic,  having  greater  tension  (osmotic  pres- 
sure). 

Hypodermic,  under  the  skin. 

Hypotonic,  having  lesser  tension  (osmotic  pres- 
sure). 

Idiosyncrasy,  individual  peculiarity. 
Implantation,  the  act  of  setting  in,  grafting  of  tis- 
sue from  one  person  to  another ; 

physiologic,  grafting  living  tissue ; 

mechanical,  grafting  dead  tissue. 
Infection,  invasion  by  disease  germs. 
Infiltration,  fluid  effusion  into  an  organ  or  tissue. 
Intravenous,  into  the  veins. 
Iodize,  to  apply  iodine. 
Iodoform,  yellow  antiseptic  powder. 
Irrigation,  constant  washing. 
Isotonicity,  state  of  having  the  same  osmotic  pres- 
sure as  the  blood  serum. 

Kilogram,  a  metric  weight,  1000  grams. 

Laryngology,   specialty   treating   disease   of   the 

larynx. 
Laxative,  a  purgative. 


254  Local  Anaesthesia 

Lege  artis,  according  to  the  law  of  the  art  (cor- 
rectly). 

Lethal,  deadly,  fatal,  causing  death. 

Lock  jaw,  trismus. 

Locked  jaw,  condition  when  the  jaws  cannot  be 
opened  or  closed  due  to  swelling  of  the  soft 
parts. 

Lues,  syphilis. 

Luetic,  syphilitic. 

Luxated,  loosened. 

Lysol,  a  disinfectant  and  antiseptic  from  cresol. 

Mandible,  the  lower  jaw. 

Maxilla,  the  jaw. 

Maxillary  sinus,  the  antrum  of  Highmore. 

Metastasis,  a  change  of  seat  in  a  disease  (a  cancer 

of  the  breast  may  produce  metastasis  in  the 

liver). 
Metastatic,  pertaining  to  metastasis. 
Millimeter,  the  thousandth  part  of  a  meter. 
Monsels'  solution,  Ferric  subsulphate  in  solution,  a 

styptic. 
Myelitis,  inflammation  of  spinal  marrow. 
Myocarditis,  inflammation  of  heart  muscle. 

Necrosis,  death  of  bone. 
Nephritis,  inflammation  of  the  kidney. 
Nerves,  sensory,  same  as  afferent,  one  transmit- 
ting from  periphery  to  center ; 

roots,  anterior,  sensory  roots ; 

posterior,  motor  roots. 


Glossary  255 

Nervous  system,  nerves  of  body  taken  together; 
central,  spinal  cord  and  brain. 

Normal  salt  solution,  a  0.6  to  0.9%  solution  of  so- 
dium chloride  in  water. 

Novocain,  a  local  anaesthetic,  discovered  by  Ein- 
horn. 

(Edema,  see  Edema. 

Ophthalmology,  science  of  structure  and  diseases 
of  the  eye. 

Ophthalmological,  pertaining  to  the  eye. 

Opiates,  opium  preparations,  hypnotics. 

Organ,  any  part  of  the  body  with  a  special  func- 
tion. 

Orgasm,  the  crisis  of  venereal  passion. 

Orthoform,  a  white  crystalline  powder  used  as  an 
antiseptic  and  anaesthetic. 

Pallor,  paleness. 

Paralysis,  the  loss  of  sensation  or  voluntary  mo- 
tion. 

Periostitis,  inflammation  of  the  periosteum. 

Peroxide  of  Hydrogen,  H,02,  an  antiseptic. 

Phenacetin,  a  coal-tar  product,  prescribed  to  allay 
pain,  a  cardiac  depressant. 

Phlebitis,  inflammation  of  a  vein. 

Pneumonia,  inflammation  of  the  lungs. 

Pulse,  expansive  impulse  of  arteries ;  thready,  one 
scarcely  perceptible. 

Pus,  fluid  product  of  suppuration. 


256  Local  Anaesthesia 

Pyemia,  condition  wherein  pyogenic  bacteria  cir- 
culate in  the  blood. 
Pyramidon,  an  antipyretic  derivative  of  antepyrin. 

Radiography,  the  art  of  making  an  X-ray  picture. 
Rhinology,  the  science  of  structure  and  diseases  of 

the  nose. 
Ringer's  solution,  an  isotonic  solution  containing 

sodium,  potassium  and  calcium  chloride. 
Roentgengram,  see  Skiagram. 

Sedative,  producing  a  sedative   (depressing)   ef- 
fect. 

Septicemia,  infection  marked  by  bacteria  being 
present  in  the  blood. 

Septic,  relating  to  sepsis  (putrefaction). 

Serum,  fluid  constituent  of  the  blood,  separated  by 
coagulation ; 
horse,  from  the  horse,  used  in  the  treatment  of 

hemorrhage ; 
human,  serum  from  human  blood. 

Shock,  marked  lowering  of  vital  activities  due  to 
injury  or  operation. 

Sinus,  a  hollow  cavity  or  pocket. 

Sinusitis,  inflammation  of  a  sinus. 

Skiagram,  the  finished  printed  X-ray  picture. 

Sloughing,  formation  of  slough  (death  of  tissue). 

Spasm,  a  convulsive  muscular  contraction. 


Glossary  257 

Spatium  pterygo  mandibulare,  a  flattened  space 
between  the  mandible  and  internal  pterygoid 
muscle,  through  which  the  mandibular  and 
lingual  nerves  pass. 

Sphygnomanometer,  instrument  to  measure  the 
blood  pressure. 

Sterile,  barren,  not  fertile,  free  from  living  mat- 
ter (free  from  bacteria). 

Sterilisation,  method  of  producing  sterility  (de- 
stroying bacteria). 

Streptococcus,  a  pyogenic  organism,  very  virile. 

Styptic,  having  the  property  of  checking  hemor- 
rhage. 

Subcutaneous,  under,  beneath  the  skin. 

Suprarenin,  see  Adrenalin. 

Surgery,  branch  of  medicine  dealing  with  opera- 
tive procedure ; 
plastic,  the  repair  of  defective  tissue  by  trans- 
plantation. 

Symphysis,  a  junction  of  bone. 

Tab.,  abbreviation  for  tablet  or  tablets. 

Tampon,  a  plug  of  lint  or  cotton. 

Tannic  arid,  from  nut  galls,  astringent  and  inter- 
nal hemostatic. 

Thrombus,  a  blood  clot  in  a  vessel  at  the  point  of 
obstruction. 

Thrombosis,  the  formation  of  a  blood  clot. 

'I' <)<>th,  one  of  the  organs  of  mastication. 

Toxicity,  a  stale  of  being  poisonous. 


258  Local  Anaesthesia 

Transfusion,  a  transfer  of  blood  into  the  veins; 
transfer  of  a  liquid  from  one  vessel  to  an- 
other. 

Trauma,  an  injury,  wound. 

Traumatic  shock,  shock  due  to  injury. 

Traumatism,  trauma. 

Trigemin,  an  anti-neuralgic. 

Trismus,  a  spasm  of  the  muscles  of  mastication. 

Urological,  pertaining  to  Urology  (science  of  dis- 
eases of  the  genito-urinary  system). 
Uterus,  the  womb. 
Uterine,  pertaining  to  the  womb. 

Venosity,  looking  like  a  vein,  bluish. 


THE    COPYRIGHTS   OF   THIS    BOOK,    IN    ALL   ENGLISH    SPEAKING 
COUNTRIES,   ARE   OWNED  BY  REBMAN   CO.,   NEW  YORK 


INDEX 


Accidentally  extracted  teeth,  117 
Action    of    Local    Anaesthetics, 

136.   162 
Adjusting  forceps  to  tooth,  45 
Adrenalin.  160 
Alcohol  and  Glycerine  Mixture, 

138 
Alcohol    for    Sterilizing,    11 
Ampules,    135 
Amyl  nitrite.  39,  228 
Anaemia,   109 
Anaesthesia,   129 
General.  129 
Local,  129,   130,  202 
Conductive,    130,    180,    205 
advantages   of,    170,   205 
where  to  use.  206 
unpleasant    effect    from, 
227 
Bv   direct  application.   130 
Infiltration,  130.  162,  168,  170 
Inhalation,   103,  205,  208 
of  Upper  Molars,  173,  194 

228,    231.    232 
Upper    Bicuspids,     173,     175. 

228     231     232 
Upper  Canines.  228,  231.  232 
Upper  Centrals,  229,  231.  232 
Upper  Six  Anteriors,  230 
Hard  palate,   176,  194 
Half    upper   jaw,    230 
Whole  upper  jaw,  230 
Lower   Molars,  231 
Lower    Biscuspids,    198.   229, 

232 
Lower  Canines,  198.  229,  232 
Lower     Centrals,    229,     231, 

232,    233 
Six   Anteriors,   230 
Half  Mandible,  230 
successful,   2H4 
uses  of  Local,  202 


effects    following    Local, 
136 

Anatomical  forceps,  31 

landmarks  of  upper  jaw, 
163,   172-177,  193,   197 
landmarks    of    Mandible, 
180-183,  188,    197,  198 

Antidotes  for  poisoning,   243 

Antiseptic  washes,  237 

Appearance    of    patient,    14 
in  sepsis,  20 
with   cardiac  disease,   14 

Application    of    forceps    to    up- 
per teeth,  46,  50,  51,  52 
Lower  teeth,  52,  55,  56,  57-59 

Applying    beaks    of    forceps    to 
tooth,  44 

Area  of  resistance,  47 

Armamentarium     for     extract- 
ing, 26 

Arteriosclerosis,    14,    161 

Asepsis,   7 

for  the  mouth  specialist,  8 

Astringent    washes,   238 

Astringents  in  hemorrhage,  108 

Bleeders,   114 

Bloodpressure   and   N20,    15 
Bromural,  23 
Buccal  nerve,   179 

Calomel  ointment,  10 

Charts  in  multiple  extractions, 

21 
Children.  Treating,   13 
Chisels,   35 

use  of,  74,  93 
Classification  of  extractions,  40 
Clinical   thermometer,    20 
Closing  forceps  about  tooth,  49 
Cocaine,    146 

History.    146 

Physiologic  action,  149 

Local  effects,  154 


259 


260 


Index 


Cold  applications,   109,   125 
Complications  of  Tooth  Extrac- 
tion,   115 
Conductive  Anaesthesia  in  Op- 
erative Dentistry,  221 
Oral  Surgery,  212 
Technique  of,  180 
Contraindications      for      Local 
Anaesthesia,  199 

Degrees  of  Locked  jaw,  122 
Diagnosis  of  Open   Antrum  or 

Cyst,    120 
Dressings,   37,    106,   125 
Drilling  out  a  tooth,   90,  93 
Drugs,  39 
Dry  heat,  105,  106 

Effects  of  hypodermic  injection 
of  water,   133 
Saline  Sol.,  133 
Hypotonic  Sol.,   134 
Hypertonic   Sol.,   134 
Elevators,   71 

use  of,  72-76 
Endocarditis  of  Dental  Origin, 

5 
Examination  of  patient,   14 
mouth,  16 
glands,  17 
jaw,  18 
tooth,  25 
root,  25 
"Extraction   Don'ts,"  24 
Extraction,  Types  of,  41 
Normal,   42 

stages  of,  42 
of  roots,  68,  69,   70,  72, 
77,  79 

apices  of  roots,  77 
Impacted   Teeth,    80,    81,    82, 

85,  86,  87 
Second  Lower  Molar  instead 

of  Third,  85 
Unerupted  Teeth,  91 
Extracting   teeth   during  preg- 
nancy,   16 


Failures   in   Conductive  Anaes- 
thesia, 227 
Fainting,    246 
Finger-protector,    23 
Flap  Operation,  77,  79,  82,  83, 
87,  88,   122 
Knife,   Author's,  30 
preparation,  69,  71,  82 
Footbath,  105 
Forces      retaining      tooth      in 

Alveolus,  49 
Forceps,   Tooth,   upper,   26,   27, 
29 

lower,    27,    28,    29 
Root,  27,  28,  29 
Bone    Cutting,    37 
Anatomical,    31 
Tongue,  34 
Forcing   a   tooth  into  Antrum, 

119 
Fracture  of  Tooth,  121 
Root,    121 

Adjoining  tooth,   117 
Alveolus,  118 
Jaw,  118 

Glossary,   249 

Grasping  upper  forceps,  42 

Lower   forceps,   52 
Gum  tissue,   about   roots,  25 
care   of,   69,    70 

Hands,  care  of,  9 
Headlight,   36 
Heat,  Dry,   105 

Moist,   105 
Hemophelia,  21,    111 
treatment,  114 
Hemorrhage,    after    extracting, 
106 

treatment    of,    108,    109, 
241,  242 

causes  of,  107,  109 
Holding  upper  forceps,  43 

Lower  forceps,   53,  54 
Hysterical  patients,   15,   23 
Hypodermic  injection  of  water, 
133 
Saline  Sol.,  133 


Index 


261 


Hypotonic   Sol.,    134 
Hypertonic    Sol.,    134 

Ichthyol,   39,   106 
Idiosyncrasies,  200 
Impacted  Teeth,  40,  80,  81,  82, 
85,  86,   87,   88,  80 
types  of,  80 
Incarcerated    Teeth.      See    Im- 
pacted Teeth 
Incising  gum,  60,  70,  87,  89.  91, 

9o 
Indications    and    Contraindica- 
tions for  Local  An.,  199 
for  Tooth  Extractions,  24 
Infections  following  Dental  Op- 
erations, 3 
Infiltration     Anaesthesia.     162, 

168,   169,   170 
Injection    Mandibular,    180 
Tuberosity,   188 
Palatine  Anterior,  194 
Palatine  Posterior,   193 
Infraorbital,   195 
Mental,    197 

of   water,    hypodermatic, 
133 
Insertion  of  needle  for  infiltra- 
tion,   107 
Instruments,    Care    of,    10 
Inspection    of   socket,    101 
Internal  Medication.  105,     109, 
112,     114,     122,     124,    125, 
207,  2:58 
Irrigation  of  socket,   102,   107 

Laxatives,   21,    125,   241 
Lie,  Telling  patients  a,  13 

Lingual    nerve    178 

Locked  jaw,    122 
Luxation  of  teeth,  15 

Mandible  180 
Mandibular  injection,  lso 

on  left  Bide,  188 
Micturition,   Involuntary,  22 
Mouth   props,  31,  74 
Mouth  gag,  :vl 


Needles,    140 

Care  of,  140,  142.   143 

Platinum  Indium,   140 

Rusty,    141 

Broken,    141 
Nerve  blocking,  130 

Supply  of  Upper   teeth,   172- 
175 

Hard  palate,   176 
Lower  teeth,   177-179 
Normal   Extractions,   40 
Novocain,    157 

Forms  of,    160 

Action    of,    160 

Tablets,    161 

I  Observation   of  patients,  14 
Odontectomy,    93 
Odontomy,  98 

Opening    Antrum    accidentally, 
118 

Locked  Jaw,   122,   124 
Operator,  Attitude  of,  6 

Position  of,  61,  65 
Oral  screw,  33 

Packing,  84.  102,  104,  108 
Pain  after  extracting,  103,  240 
after  injections,  136,  165 
227. 
Palatine      injection,      Anterior, 
194 
Posterior,    193 
Palpating       External       oblique 

line,  181 
Placing    forceps   over   gum,   69 
Position   of   patient,   22 

of  operator,  61-65 
Powderblower,   35 
Postextractive  treatment.    101 
Pregnancy    and    Tooth    Extrac- 
tion,   16 
Preparation    of   patient,    22 
Prescriptions      and     Formulae. 

235 
Pressure  in  Hemorrhage,  108 
Proprietary    Anaesthetic    Solu- 
tions,   134 


262 


Index 


Removal     of     Impacted     teeth, 
80-90 

Unerupted  teeth,  91-100 

Gum   tissue,  91 

Tooth  from  socket,  49 
Replantation,  Physiological,  117 

Mechanical,    116 
Requisites  for  Local  Anaesthe- 
sia, 226,  228 

of  Solutions  for  Loc.  An.,  132 
Retractors,  34 
Retromolar    triangle,    183 
Ringers    Solution,    135 
Rotation  of  teeth,   83 
Root  Extractions,  types,  40 

Normal,    40 

Surgical,   40 

Sedatives,  23,   238,  239,   240 
Sense  of  Asepsis,  7 
Serum  in  Hemorrhage,  114 
Shock  in  Dental  Operations,  22 

Oral   Surgery,  207 

Treatment,    124 

Signs  of,  22 
Solvent  medium,   133 
Sphygnomanometer,    15 
Splinting  loose  teeth,  116 
Sponges,   How  to  make,   38 
Standing    in   front    of   patient, 
63,   67 

at  side,  63 

behind,  66 
Steps  of  Normal  Extraction,  42 

Injection  with  steel  needle, 144 
Pt.  Ir.  needle,  145 
Sterilization 

Improper,   8 

of    water    for    Local    Anaes- 
thesia,  137 

of  Instruments,  8 

of  Syringe,  10,  138 

of  Needles,  10,  141 

of  Mouth,  23 

of  Mirrors,   10 

of  Nerve  Broaches,  11 

of  Hands,  9 
Structure  of   Upper   Jaw,    163, 

166 
Syringes,  Care  of,  10 


Technique     of     Local     Anaes- 
thesia,  144,    145 

Infiltration,  164 

Mandibular  Injection,  180 

Tuberosity  Injection,   188 

Posterior  Palatine  Injection, 
193 

Anterior    Palatine   Injection, 
194 

Infraorbital   Injection,    195 

Mental  Injection,  197 

Conductive   Anaesthesia,    180 

Surgical  Extractions,  126 

Normal   Extractions,   42 

Root  Extractions,  68 

Removal  of  Impacted   Teeth, 
80 

Removal  of  Unerupted  Teeth, 
91 

Normal  Root  Extractions,  42 

Surgical     Root     Extractions, 
78 
Thiersch's  Solution,  125,  235 
Tooth   Extraction  during  Preg- 
nancy,   16 
Treatment  of  Socket  after  Ex- 
traction,  101 
Treating  Children,  13 
Treatment  for  Fainting,  246 

Hiccoughs,   246 

Heartfailure,   246 

Epistaxis,   246 

Collapse,  247 

Shock,  247 

Hysterical  Attacks,  247 

Nervous   Attacks,   247 

Convulsions,  248 

Complications    after    extrac- 
tions, 115 

Poisonings,  243 
Trigonum   retromolar s,   183 
Trismus,   122 

Unerupted    teeth,    41,    91,    94, 
95,  98 
Occurrence  of,  99 

Wet  Dressings,   106,  125 

X-Ray,  77,  83,  92,  97,  100,  121, 
122 


DATE  DUE 

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